Every finding on record at Penacook Place, Inc

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was severely cognitively impaired and dependent on staff to meet his/her care needs, the facility failed to ensure staff consistently implemented and followed their abuse policy related to protection and reporting abuse allegations, when on 12/13/25 Certified Nurse Aide (CNA) #2 witnessed, but did not immediately report, that Resident #1 was allegedly verbally abused by a staff member, and waited until 12/16/25 (three days later) to report the incident, therefore placing Resident #1 and other residents on the unit at risk for potential abuse.Findings include:Review of the Facility Policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 03/01/25, indicated it is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment immediately to the Administrator of the facility. The Policy indicated the facility will develop and operationalize policies and procedures for the protection of residents and for the reporting of abuse. The Policy indicated its purpose was to assure the facility is doing all that is within its control to prevent occurrences. The Policy indicated it would protect residents from harm during an investigation.Review of Resident #1's clinical record indicated his/her diagnoses included Dementia with Behavioral Disturbance and Anxiety.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 11/04/25, indicated he/she had severely impaired cognition, disorganized thinking and rejected care daily.Review of Resident #1's Care Plan, reviewed and renewed with his/her November 2025 MDS, indicated he/she was at risk for altercation in mood, such as agitation, tearfulness changes in mood, due to dementia with behavioral disturbance and disorientation. The Care Plan indicated that interventions included to administer medications, behavioral health consults as needed and to monitor for acute episode feelings or sadness.During a telephone interview on 01/28/26 at 1:20 P.M., CNA #2 said on 12/13/25 at 6:30 P.M., while supervising residents with severe cognitive impairment in the activity room, CNA #1 entered and Resident #1 told CNA #1 loudly to get out of my uncle's restaurant! CNA #2 said CNA #1 responded back loudly mind your own business, I am not talking to you. CNA #2 said Resident #1 then stated to CNA #1 loudly listen you ugly bitch, and that CNA #1 replied back to Resident #1 saying you're an ugly bitch, and left with another resident who had also been sitting in the activity room, to provide his/her care. CNA #2 said she did not confront CNA #1 at the time of the incident because she felt CNA #1 would not acknowledge that she was wrong to speak to Resident #1 in that manner. CNA #2 said she did not report the incident to anyone until around 8:00 A.M. on 12/16/25 (three days later). CNA #2 said she forgot about the incident until she overheard Unit Manager #1 and Nurse #1 discussing Resident #1. CNA #2 said she reported the incident to them and assumed they would report it to the Director of Nurses.CNA #2 said around 9:00 A.M. on 12/16/25 while speaking with the Scheduling Coordinator, she told her about the incident. CNA #2 said she did not mention to her that Unit Manager #1 and Nurse #1 were already made aware of it. CNA #2 said the Scheduling Coordinator immediately reported the incident to the Human Resource Director.CNA #2 said she thought allegations of abuse needed to be reported to the Director of Nurses (DON) or the Administrator within two hours of the incident. CNA #2 said she did not report it until 12/16/25 (three days later) because the incident occurred in the evening over the weekend and neither of them (DON or Administrator) were at the Facility. CNA #2 said she had not received instruction on what to do if neither the DON and/or the Administrator were in the Facility.As a result of CNA #2 waiting three days to report the incident, CNA #1 continued to work on Facility unit(s) placing the residents at risk for potential abuse. Review of CNA #1's Time Detail indicated she worked the following:- 12/13/25; (incident occurred around 6:30 P.M.) CNA #1 worked until 10:42 P.M. -12/14/25; from 3:35 P.M. to 10:57 P.M.-12/16/25; from 3:55 P.M. to 5:02 P.M. (when suspended)During an interview on 01/20/26 at 1:35 P.M., Nurse #1 said she did not recall receiving any information on 12/16/25 from CNA #2 related to Resident #1 being called a bitch by a CNA or any other verbally abusive statement.During a telephone interview on 01/30/26 at 11:25 A.M., Unit Manager #1 said she did not recall receiving any information on 12/16/25 from CNA #2 related to Resident #1 being called a bitch by a CNA or any other verbally abusive statement.During an interview on 01/20/26 at 2:10 P.M., the Scheduling Coordinator said mid-morning on 12/16/25, CNA #2 came to her office and stated that over the weekend she witnessed CNA #1 tell Resident #1 to mind his/her own business. The Scheduling Coordinator said CNA #2 told her that Resident #1 replied listen you ugly bitch to CNA #1, and CNA #1 repeated it back at Resident #1 stating no, you listen you ugly bitch. The Scheduling Coordinator said she immediately reported the allegation of verbal abuse to the Human Resource Director.During an interview on 01/20/26 at 2:35 P.M., the Human Resource Director said on 12/16/25 at around 2:45 P.M., the Scheduling Coordinator along with CNA #2 reported to her that she (CNA #2) witnessed CNA #1 tell Resident #1 to mind his/her own business and repeated back to Resident #1 the statement to get out, you ugly bitch. The Human Resource Director said she proceeded to a meeting that was going to be held with the DON and another staff member for an unrelated issue. The Human Resource Director said she did not immediately report the alleged incident of abuse to the DON but waited to report it after the meeting ended around 4:00 P.M., an hour later.During an interview on 01/20/26 at 9:30 A.M., the DON said it was difficult to recall, but said she thought the Scheduling Coordinator reported to her at 3:00 P.M. on 12/16/25 that on 12/13/25 CNA #2 witnessed CNA #1 allegedly verbally abused Resident #1.The DON said she discovered that CNA #1 was working on the Unit on 12/16/25, immediately removed her from it and began to investigate. The DON said it was expected that staff members immediately report any alleged incidents of abuse per Facility Policy.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure staff consistently implemented and followed policies and procedures to immediately report an altercation of abuse to Administrative staff as required, so the Facility could report the incident to the State Survey Agency, within the required time frames. On 12/13/25 although a staff member witnessed Certified Nurse Aide (CNA) #1 engage in a suspected verbally abusive altercation with Resident #1, it was not reported to Administration until 12/16/25, and therefore not reported to their State Survey Agency, until three days later.Findings include: Review of the Facility Policy titled Abuse, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, indicated all reports of resident abuse are reported to local, state and federal agencies (as required by current regulations). The Policy indicated that if abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The Policy indicated the administrator or individual making the allegation immediately reports his or her suspicion to the following agencies which included the state licensing/certification agency responsible for surveying/licensing the facility. The Policy indicated that immediately is defined as within two hours of an allegation involving abuse.Review of Resident #1's clinical record indicated his/her diagnoses included Dementia with Behavioral Disturbance and Anxiety.During a telephone interview on 01/28/26 at 1:20 P.M., CNA #2 said on 12/13/25 at 6:30 P.M., while supervising residents with severe cognitive impairment in the activity room, Resident #1 told CNA #1 get out of my uncle's restaurant! and CNA #1 responded back loudly mind your own business, I am not talking to you. CNA #2 said Resident #1 then stated to CNA #1 loudly listen you ugly bitch, and said CNA #1 replied back to Resident #1 you're an ugly bitch, and left the room with another resident that had also been in the activity room, to provide his/her care. CNA #2 said she did not report the incident to anyone until around 8:00 A.M. on 12/16/25. CNA #2 said she forgot about the incident until she overheard Unit Manager #1 and Nurse #1 discussing Resident #1. CNA #2 said she reported the incident to them.CNA #2 said around 9:00 A.M. on 12/16/25 while speaking with the Scheduling Coordinator, she also told her about the incident. CNA #2 said the Scheduling Coordinator immediately reported the incident to the Human Resource Director.CNA #2 said she did not report it until 12/16/25 (three days later) because the incident occurred in the evening over the weekend and neither of them (DON and Administrator) were at the Facility. During an interview on 01/20/26 at 1:35 P.M., Nurse #1 said she did not recall receiving any information on 12/16/25 from CNA #2 related to Resident #1 being called a bitch by a CNA or any other verbally abusive statement.During a telephone interview on 01/30/26 at 11:25 A.M., Unit Manager #1 said she did not recall receiving any information on 12/16/25 from CNA #2 related to Resident #1 being called a bitch by a CNA or any other verbally abusive statement.During an interview on 01/20/26 at 2:10 P.M., the Scheduling Coordinator said mid-morning on 12/16/25, CNA #2 told her that over the weekend she witnessed CNA #1 tell Resident #1 to mind his/her own business, that Resident #1 replied listen you ugly bitch to CNA #1, and CNA #1 repeated it back to Resident #1 stating no, you listen you ugly bitch. The Scheduling Coordinator said she immediately reported the allegation of verbal abuse to the Human Resource Director.During an interview on 01/20/26 at 2:35 P.M., the Human Resource Director said on 12/16/25 at around 2:45 P.M., the Scheduling Coordinator along with CNA #2 reported to her that she (CNA #2) witnessed CNA #1 tell Resident #1 to mind his/her own business and repeated back at Resident #1 the statement to get out, you ugly bitch. The Human Resource Director said she had a meeting with the DON, and at the end of the meeting she reported what CNA #2 told her.During an interview on 01/20/26 at 9:30 A.M., the DON said it was difficult to recall but thought the Scheduling Coordinator reported to her at 3:00 P.M. on 12/16/25 that on 12/13/25 CNA #2 witnessed CNA #1 allegedly verbally abuse Resident #1.The DON said she discovered that CNA #1 was working on the Unit on 12/16/25, immediately removed her from it and began to investigate. The DON said it was expected that staff members immediately report any alleged incidents of abuse, per Facility Policy, to enable the Facility to report the incident to the State Agency within two hours of it being known to have occurred. Review of the Health Care Facility Reporting System indicated the Facility's report was created on 12/16/25 at 5:37 P.M. reporting that Resident #1 was allegedly verbally abused by CNA #1, which was three days after the alleged verbally abusive incident took place.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when on 03/18/25 he/she was administered the incorrect dose of long acting insulin. Resident #1 experienced an adverse reaction, including lethargy and malaise, for which he/she required treatment and increased monitoring by nursing until his/her blood sugar level stabilized. Findings include: The Facility Policy, titled Insulin Administration, dated revised 09/2014, indicated nursing would verify the type of insulin, dosage requirements, strength, and method of administration before administration, to confirm it corresponds with the physician's orders. The Facility Policy, titled Adverse Consequences and Medication Errors, dated revised 02/2023, indicated that a medication error was defined as the preparation or administration of drugs or biologicals which was not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principals of the professional providing the services. Review of the Facility's Incident Report Form, dated 03/18/25, indicated that at 11:30 A.M., Resident #1's routine blood sugar check indicated his/her blood sugar was 52 milligrams per deciliter (mg/dL) (indicative of hypoglycemia, low blood sugar defined by a blood glucose level below 70 mg/dL), he/she was asymptomatic at that time, ate some fig newtons and juice, and went to the main dining room for lunch. The Incident Report indicated Resident #1 later became symptomatic, was pale, sweating, cool and clammy, and said he/she did not feel well. The Incident Report indicated the Facility discovered that Nurse #1 had administered Resident #1's Toujeo (long acting insulin) 300 units/mL using a standard 100 unit/ml insulin syringe, and had therefore administered three times the prescribed dose of insulin, in error. Review of Resident #1's Nurse Practitioner Note, dated 03/18/25, indicated he/she was given Toujeo 108 units that morning instead of the prescribed dose of 36 units. Resident #1 was admitted to the Facility in August 2021, diagnoses included diabetes which was managed with insulin. Review of Resident #1's Order Summary Report for March 2025 indicated he/she had a physician's orders for Toujeo Max Solostar Subcutaneous (under the skin) Solution Pen-Injector 300 unit/mL, inject 36 units subcutaneously one time a day. Review of the Highlights for Prescription Information Insert for Toujeo (long acting insulin) Unit 300 Insulin Glargine pre-filled subcutaneous pen, dated revised 08/2024, indicated: -Toujeo was supplied in multi-dose pre-filled pens, and doses were injected using single use needles which attached to the pen. -Do not use a syringe to remove Toujeo from the Toujeo pre-filled pen, as it could cause you to give yourself too much insulin. Toujeo has three times as much insulin (300 units/mL) in one mL as compared to other insulin glargine products (100 units/mL) pens. According to the American Diabetes Association, people with diabetes should have blood sugar levels of 80-130 milligrams per deciliter (mg/dL) before eating a meal (fasting), and less than 180 mg/dL about 1-2 hours after eating a meal, however these ranges varied per individual. Review of Resident #1's Blood Sugar Summary from 03/01/25 to 03/17/25 indicated his/her capillary blood sugar ranged between 88 mg/dL to 290 mg/dL, and was monitored by nursing four times daily. Review of Resident #1's Nurse Progress Note, dated 03/18/25, indicated during his/her routine blood sugar check at 11:30 A.M., his/her blood sugar level was 52 mg/dL (low), he/she was not symptomatic at the time, he/she ate two fig newtons, 16 ounces of cranberry juice and left his/her unit to go to the main dining room. The Note indicated that once Resident #1 was in the main dining room, he/she told the Director of Nurses (DON) about the low blood sugar level, said he/she was feeling sweaty and looking forward to eating lunch so he/she could feel better. The Note indicated Resident #1 said he/she had received his/her normal insulin injection between 08:00 A.M. and 09:00 A.M., that morning, that he/she had eaten a large lunch, continued to complain of feeling unlike him/herself. The Note indicated Resident #1 appeared cool, clammy and was pale. Further review of the Nurse Progress Note indicated his/her blood sugar was 55 mg/dL at 12:15 P.M., and Nurse Practitioner #1 provided new orders for the following: - Glucose Chewable Tablets - Intravenous Dextrose 5% in Water (D5W), 1,000 mL at a rate of 75 ml an hour (times one). - Check his/her blood sugar every 30 minutes for two hours, then every two hours until 07:30 A.M. on 03/19/25. Review of Resident #1's Blood Sugar Summary indicated his/her blood sugars were monitored as ordered, and between 12:30 P.M. on 03/18/25 into 07:38 A.M., on 3/19/25, his/her blood sugars ranged from 94 mg/dL to 389 mg/dl. Review of Resident #1's Nurse Progress Note, dated 03/19/25, timed 07:35 A.M., indicated nursing assessed him/her throughout the night, he/she had no symptoms of hypoglycemia, and he/she received D5W via IV, as ordered. During an interview on 04/29/25 at 11:07 A.M., Nurse #1 said that on 03/18/25, he was Resident #1's assigned nurse, that he was familiar with Resident #1 and was normally assigned as his/her nurse. Nurse #1 said that on 03/18/25 at 08:00 A.M., the needles that attach to Resident #1's Toujeo pre-filled pen were not in the medication cart, that he did not look elsewhere or ask other staff where to find more pen needles, and used an insulin syringe that measured 100 units/ml to draw up 36 units from the pre-filled pen, then injected Resident #1 with that syringe. Nurse #1 said he did not realize that the Toujeo insulin concentration was 300 units/ml, and said since he used a syringe that measured 100 units/ml, he administered Resident #1 three times the physician's ordered dose of Toujeo, in error. During an interview on 04/29/25 at 08:48 A.M., the Director of Nurses (DON) said Nurse #1 should only have injected Resident #1's Toujeo using the pre-filled pen and needle, but had used an insulin syringe, which led to Resident #1 receiving three times the prescribed dose, and experiencing symptoms of low blood sugar. The DON said there were more needles for insulin pens available in the Facility on 03/18/25 in the supply room on the unit. On 04/29/25, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. 03/18/25, Resident #1 was administered IV D5W, was monitored by nursing, and recovered from his/her hypoglycemic episode caused by the accidental overdose of insulin. B. 03/18/25, The Sentinel Event Root Cause Analysis Report was created which indicated Facility's Leadership developed a plan to correct the deficient practice to ensure that residents were administered insulin doses as prescribed, and that residents whose insulin was administered via multi-dose pens were only administered doses via the pen/needle set up. C. 03/18/25, The DON completed an audit of all residents with high concentration insulin to ensure nursing was not drawing from high dose insulin pens using a syringe. D. 03/18/25, The DON completed an audit of each unit to ensure there were enough insulin pen needles and that licensed nurses were aware of where to obtained additional needles, if needed. E. 03/18/25, The DON implemented new High-Dose alert labels for insulin with concentrations greater than 100 units/ml. F. 03/18/25, The DON and MDS Nurse discussed with the Medial Director and obtained approval to implement new standing orders for a new protocol specific to hypoglycemia for all residents with diabetes or prediabetes. G. 03/19/25, The DON and MDS Nurse audited all residents with diabetes and prediabetes and the new standing orders for hypoglycemia protocol were implemented. H. 03/20/25, The DON and ADON educated licensed nursing staff regarding insulin pen use, verifying insulin dose and concentration, blood glucose testing, hypoglycemia protocol, symptoms of hypoglycemia and hypoglycemic rescue medications. I. 03/18/25, The DON initiated audits for all residents with high-dose insulin pens for four weeks and will continue to do so monthly for two months to ensure that high-dose insulin pens are labeled, that pen needles are well stocked, and that nurses are not drawing from pens with insulin syringes. J. The Facility will monitor compliance at monthly and quarterly Quality Assurance Meetings. K. The Director of Nurses and/or designee is responsible for ongoing compliance.

Based on observations, interview and record review, the facility failed to follow the plan of care for one Resident (#100) by not following a doctor's order to offload heels, out of a total sample of 24 residents. Findings include: Resident #100 was admitted to the facility in August 2023 with diagnoses including dementia and pain in both feet. Review of Resident #100's most recent Minimum Data Set (MDS) assessment, dated 5/2/24, indicated the Resident had a Brief Interview for Mental Status exam score of 3 out of a possible 15, which indicated he/she had severe cognitive impairment. The MDS also indicated Resident #100 is dependent on staff for all bed mobility tasks. On 5/06/24 at 8:37 A.M., Resident #100 was observed lying in bed with both heels directly on the bed. There was no pillow present in the bed or in the room to offload pressure from Resident #100's heels. On 05/07/24 at 7:36 A.M., 8:37 A.M., and 1:47 P.M., Resident #100 was observed lying in bed with both heels directly on the bed. There was no pillow present in the bed or in the room to offload pressure from Resident #100's heels. On 5/08/24 at 7:38 A.M., Resident #100 was observed lying in bed with both heels directly on the bed. There was no pillow present in the bed or in the room to offload pressure from Resident #100's heels. Review of the nursing note dated 5/02/24 indicated the following: Bruising noted on R (right) lateral foot. yellowish/blue in color. NP (nurse practitioner) made aware and assessed. NP informed that this resident is on 2 different blood thinners. NP looking into these medications as it may be the cause of resident easily bruising. HCP (health care proxy) updated. Review of the skin assessment dated [DATE] indicated Resident #100 had redness on his/her left heel and bruising to his/her right foot. Review of Resident #100's physician orders indicated the following order: Offload heels every shift when in bed, initiated on 4/24/24. During an interview on 5/08/24 at 7:39 A.M., Nurse (#2) said Resident #100's heels should be offloaded. During an interview on 5/08/24 at 10:02 A.M., the Director of Nursing said she expects all orders to be followed as ordered.

Based on observation, record review, and interview, the facility staff failed to provide supervision with meals for one Resident (#37) out of a total sample of 24 residents. Findings include: Resident #37 was admitted to the facility in October 2021 with diagnoses including dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/25/24, indicated that Resident #37 could not participate in the Brief Interview for Mental Status exam and was assessed by staff to have severely impaired cognition. The MDS further indicated that Resident #37 requires supervision with eating. Review of Resident #37's current activities of daily living care plan indicated that Resident #37 requires supervision after setup with eating. Review of the most recent Functional Abilities and Goals Assessment, dated 4/26/24, indicated that Resident #37 requires supervision or touching assistance with meals. Review of the task performance documentation for the last 30 days indicated that Resident #37 required varying assistance levels between independence and dependence with meals. During an observation on 5/06/24 at 9:29 A.M., Resident #37 was observed in his/her room, in bed eating breakfast. There were no staff present to provide supervision. Resident #37 was struggling to eat toast with a spoon. During an observation on 5/07/24 at 8:03 A.M., Resident #37 was observed in his/her room, in bed eating breakfast. There were no staff present to provide supervision. During an observation on 5/08/24 at 8:28 A.M., Resident #37 was observed in his/her room, in bed eating breakfast. There were no staff present to provide supervision. During an interview on 5/08/24 at 8:51, Nurse (#2) said that Resident #37 requires supervision with meals and sometimes assistance. During an interview on 5/08/24 at 8:39 A.M., the Director of Nursing said that residents that require supervision should be in the hallway or dining room when eating to be supervised and if a resident does not want to leave their room, then a staff member should be sitting in the resident's room while the Resident eats.

Based on observation, interview, record review, and policy review, the facility failed to ensure that one Resident (#57), out of 24 total sampled residents, received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to obtain weekly wound measurements and failed to obtain recommendations for wound treatments from a follow-up physician appointment for Resident #57. Findings include: The facility policy titled Skin Tears - Abrasions and Minor Breaks, Care of, revised September 2013, indicated, but was not limited to: -Obtain a physician's order as needed. Document physician notification in medical record. -Review the resident's care plan, current orders, and diagnoses to determine resident's needs. -Generate a Non-Pressure form and complete. Resident #57 was admitted to the facility in October 2022 with diagnoses including peripheral vascular disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/07/24, indicated that Resident #57 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. During an interview on 5/06/24 at 8:40 A.M., Resident #57 said he/she has a wound that never healed on his/her right amputation incision. The surveyor observed a dressing on his/her right amputated residual limb. Review of the active physician's order indicated the following order: -Residual limb wound care: Cleanse wound w/NS (normal saline), pat dry. Pack wound with one sterile 4x4 gauze (DRY DRESSING). May secure with another 4x4 gauze and tape. When changing dressing, DO NOT dampen dressing. Review of the plan of care related to the wound on the suture line of the right below the knee amputation, dated 1/04/24, indicated: -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations, initiated 10/20/22. Review of Resident #57's medical record failed to indicate any weekly wound assessments were completed for his/her non-healing surgical wound. Review of Resident #57's medical record on 5/07/24 indicated the last time the non-healing surgical wound had measurements documented was on 2/22/24, over 10 weeks prior. During an interview on 5/07/24 at 8:39 A.M., Nurse (#4) said Resident #57 should have weekly measurements done in the facility for his/her non-healing surgical wound. Nurse #4 said Resident #57 is followed by a vascular physician in the community for his/her non-healing surgical wound but is unable to locate documentation from recent visits or any weekly wound assessments or measurements completed since he/she was seen by the in-house wound provider in on 1/02/24. During an interview on 5/07/24 at 8:52 A.M., the Assistant Director of Nursing (ADON) said she had told the Unit Manager multiple times that weekly wound measurements and assessments were needed for Resident #57, as they were not being done. As well, the ADON said she told the unit manager multiple times that documentation from the vascular physician needed to be obtained because the facility didn't have it. The ADON said Resident #57's non-healing surgical wound should have been assessed with measurements weekly but was not. During a follow-up interview on 5/07/24 at 9:39 A.M., Nurse #4 provided the surveyor with paperwork from Resident #57's two most recent vascular physician progress notes dated 3/06/24 and 4/03/24. Nurse #4 said this documentation was obtained on that day. Nurse #4 said she would expect notes from a doctor's appointment to be sent back with the Resident and be reviewed for any order changes needed and that if the documentation did not return with the resident, that a nurse should have reached out to the doctors office and attempted to get it it faxed over the same day. Review of the vascular physician progress note, dated 4/03/24, indicated: -We placed bacitracin in the wound and put a dressing back on. -He/she should continue with bacitracin dressings and [sic] a daily basis. I will see her back in 4 weeks for a wound check. During an interview on 5/07/24 at 1:21 P.M., Nurse #4 said paperwork should be reviewed as soon as possible after a resident returns from an appointment for any recommendations. Nurse #4 said the facility's Nurse Practitioner (NP) defers to the vascular physician for treatment orders for Resident #57 because the in-house wound team no longer follows him/her, but that since the paperwork from the 4/03/24 appointment was never obtained the recommendation was missed. Nurse #4 said the Nurse Practitioner would like to observe the wound change today before approving the order, since it had been over a month since it was recommended. Nurse #4 said the follow-up appointment was not scheduled in time because they didn't have the paperwork. Review of nursing progress note, dated 5/07/24, indicated: -Spoke with NP (nurse practitioner) regarding delay in care for her wound, ordered from vascular surgery. Resident has been followed by Vascular surgery outpatient. Resident's wound will be evaluated by the NP at the time of the dressing change that will be scheduled for this afternoon, to assess and decide if the treatment which has been suggested by vascular is appropriate and will then be added to the plan of care if so. Resident will have a follow up on 5/15/24 at 12 PM. On 5/7/24 at 2:20 P.M., the surveyor observed the wound dressing change with Nurse #3 and the Nurse Practitioner. The Nurse Practitioner said she would have approved the wound recommendation from the vascular physician and will change the order at this time. During an interview on 5/07/24 at 1:50 P.M., the Director of Nursing (DON) said Resident #57 should have had weekly wound assessments including measurements completed. The DON said the nurses on the floor are responsible for obtaining paperwork after an appointment and ensuring all recommendations are reviewed with the physician. The DON said if paperwork is not sent back from the appointment, then the nurse, or a delegate, should call that day to attempt to obtain the paperwork.

Based on observations, record reviews and interviews, the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to ensure oxygen administration was in accordance with the medical plan of care for one Resident (#5) out of a total sample of 24 residents. Findings include: The facility policy titled Oxygen Administration, undated, indicated the following but not limited to: -The purpose of this procedure is to provide guidelines for safe oxygen administration. -Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #5 was admitted to the facility in June 2023 with diagnoses including chronic obstructive pulmonary disorder, neoplasm of bronchus or lung, chronic respiratory failure and dependent on supplemental oxygen. Review of Resident #5's most recent Minimum Data Set (MDS) assessment, dated 4/18/24, indicated Resident #5 scored a 10 out of 15 on the Brief Interview for Mental Status exam indicating that he/she had moderately impaired cognition. The MDS further indicated Resident #5 is dependent on oxygen. On 5/06/24 at 8:43 A.M., Resident #5 was observed lying in bed wearing oxygen via a nasal cannula at 3.5 liters/ minute. The oxygen concentrator filters were covered with a thick layer of dust. On 5/07/24 at 9:00 A.M., Resident #5 was observed lying in bed wearing oxygen via nasal cannula at 3.5 liters/ minute. The oxygen concentrator filters were covered with a thick layer of dust. On 5/07/24 at 10:46 A.M., Resident #5 was observed lying in bed wearing oxygen via nasal cannula at 3.5 liters/ minute. The oxygen concentrator filters were covered with a thick layer of dust. Review of the current physicians' orders indicated the following orders: -Oxygen continuous at 4 liters/minute via nasal cannula every shift for shortness of breath care and comfort. -Change tubing and clean air filter weekly every night shift every Sunday. -Change oxygen/nebulizer tubing and clean filter every evening shift every Monday. Review of the Treatment Administration Record for May 2024 indicated that the oxygen tube and filter was changed on Sunday 5/05/24 and that nursing staff was monitoring for oxygen administration at 4 liters/minute via nasal cannula every shift. Review of Resident #5's emphysema/COPD, chronic respiratory failure with dependent oxygen continuous use care plan, last revised 8/30/23, indicated the following intervention: -Oxygen settings per physician orders. During an interview on 5/07/24 at 10:53 A.M., Nurse #1 said the oxygen should be set at 4 liters/minute and that the filters should not have a thick coat of dust if they were changed two days ago. Nurse #1 further said physicians orders should be followed as ordered. During an interview on 5/08/24 at 8:35 A.M., the Director of Nursing said the expectation is for nurses to follow physician's order for oxygen setting and changing tubing and filters.

Based on record reviews, policy reviews and interviews, the facility failed to provide care and services consistent with professional standards for two Residents (#103 and #57) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) out of a total sample of 24 residents. Specifically, the facility failed to ensure that clamps and pressure dressings were kept with the Resident's #103 and #57 in case of an emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine). Findings include: The facility policy titled End-Stage Renal Disease, Care of a Resident with (sic), dated as revised September 2023, indicated the following but not limited to: -Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. -Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. -How to recognize and intervene in medical emergencies such as hemorrhages and septic infections. 1.) Resident #103 was admitted to the facility in September 2023 with diagnoses including end stage renal disease, dependent on renal dialysis. Review of Resident #103's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she was cognitively impaired. The MDS further indicated the Resident was dependent on dialysis. Review of Resident #103's medical record indicated the following orders: -Check dialysis right upper chest tunneled catheter dressing every shift for bleeding or signs/symptoms of infection, notify practitioner if present every shift for monitoring. -If dialysis tunneled catheter of right upper chest dressing becomes dislodged, apply dry clear dressing and call practitioner as needed for maintenance check every shift. On 5/07/24 at 7:56 A.M., Resident #103 was observed lying in his/bed. The surveyor did not locate emergency clamps or pressure dressing with the Resident or in the Resident's room. During an interview on 5/07/24 at 10:55 A.M., Nurse #1 said the emergency clamp and pressure dressing should be taped to the wall in the Resident's room at all times. 48990 2.) Resident #57 was admitted to the facility in October 2022 with diagnoses including end-stage renal disease, peripheral vascular disease and diabetes. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/07/24, indicated that Resident #57 was cognitively intact as evidenced by a Brief Interview for Mental Status exam score of 15 out of 15. The MDS further indicated Resident #57 received dialysis. Review of the active physician's order, dated 7/28/23, indicated Resident #57 had dialysis every Monday, Wednesday, and Friday. Review of the active physician's order, dated 3/4/23, indicated: -Left IJ (internal jugular vein) tunneled HD (hemodialysis) catheter. For care, please F/U (follow up) with directed Tx (treatment) orders from the primary surgeon. Review of the plan of care related to dialysis, dated 10/02/2023, indicated: - Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. During observation and interview on 5/06/24 at 8:40 AM, Resident #57 said he/she receives dialysis through tunneled hemodialysis catheter in his/her left chest. Resident #57 said there is not a dialysis emergency kit in his/her room with clamps and pressure dressings. The surveyor did not observe an emergency kit in Resident #57's room. During an interview on 5/07/24 at 8:26 A.M., Nurse (#3) said he doesn't know where dialysis emergency kits are located or where he would obtain emergency supplies if Resident #57 had unexpected bleeding from his/her tunneled hemodialysis catheter During an interview on 5/07/24 at 8:39 A.M., Nurse (#4) observed Resident #57's room with the surveyor and said there should be a dialysis emergency kit with a clamp available in Resident #57's room for use if unexpected bleeding occurred from the tunneled hemodialysis catheter, but that there was not. During an interview on 5/0/24 at 1:50 P.M., the Director of Nursing said there should be a dialysis emergency kit located in the room of every resident who receives dialysis which contains clamps and pressure dressings in case of an emergency.

Based on records reviewed, interviews and review of surveillance camera video footage, for one of three sampled residents (Resident #1), who had a diagnosis of Alzheimer's disease and was cognitively impaired, the Facility failed to ensure he/she was treated in a respectful and dignified manner which included being free from the use of restraints, when on 11/20/23, Certified Nurse Aide (CNA) #1 used a plastic bag to secure one of the wheels of Resident #1's wheelchair to restrict his/her movement and limit his/her ability to self propel the wheelchair on his/her own. Findings include: Review of the Facility Policy titled Use of Restraints, no date, indicated that examples of devices that are/might be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vests, wheelchair safety bars, Geri-chairs, lap cushions and lap trays that the resident cannot remove. Resident #1 was admitted to the Facility in April 2022, diagnosis included chronic kidney disease, Meniere's disease, spinal stenosis, and Alzheimer's disease. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was cognitively impaired and had an invoked Health Care Proxy (HCP). Review of the Facility's Internal Investigation, dated 11/20/23, indicated that Resident #1's son came in to visit and was unable to move the resident in his/her wheelchair. The Investigation indicated they found that a plastic bag had been tied to Resident #1's wheelchair, effectively immobilizing him/her. The Investigation indicated that upon review the facility's video surveillance camera footage, it was confirmed that Certified Nurse Aide (CNA) #1 was the one who tied the plastic bag to the wheel of the wheelchair. The Investigation indicated that CNA #1 acknowledged she placed the plastic bag around Resident #1's wheelchair. Review of the surveillance camera video footage clips provided by the Facility, from the day shift (7:00 A.M. to 3:00 P.M.) dated 11/20/23 from 12:56:14 to 12:57:17, illustrated the following: -12:56:20, a staff is seen bringing Resident #1 in to the dining room. -12:56:31, Resident #1 can be seen self propelling in his/her wheelchair around the unit towards the dining room door, and CNA #1, who is standing by the door, can be seen interacting with Resident #1. -12:56:34, Resident #1 remains at the door to the dining room, and CNA #1 walks toward the cabinet area. -12:56:40, CNA #1 opens a cabinet door, pulls out a plastic bag, and walks toward Resident #1, who is still self propelling around in the area of the dining room. -12:56:56, CNA #1 is seen attaching the plastic bag in the back to the wheelchair and appears to be securing it. During an interview on 12/18/23 at 11:15 A.M., Certified Nurse Aide (CNA) #1 said she was concerned about Resident #1 wandering around, that he/she might have an altercation with another resident on the unit who also wanders. CNA #1 said she was only trying to avoid an altercation between the two residents and was not thinking of it as being restrained at the time, but said now she understands and that it was a mistake. During an interview on 12/19/23 at 11:00 A.M., Activities Assistant (AA) #2 said that Resident #1's son came to visit, wanted to move to a quiet room to visit with Resident #1, noticed the wheelchair was stuck and unable to move. AA #2 said she came over to check Resident #1's wheelchair and brakes, and noticed that there was a plastic bag secured tightly between the wheel and the seat frame. AA #2 said that this restricted the movement of Resident #1's wheelchair. AA #2 said immediately reported to Resident #1's nurse. During an interview on 12/05/23 at 2:21 P.M., the Director of Nurses (DON) said that she was notified by staff that Resident #1's son came to visit, was unable to move the resident in his/her wheelchair, and that it appeared that someone had tied the plastic bag to a wheel. The DON said she interviewed CNA #1, and that after they told her that they had reviewed the surveillance camera video footage from the unit, CNA #1 admitted securing the plastic bag to the wheelchair. The DON said CNA #1 told her she was only trying to avoid an altercation between Resident #1 and another resident that was also wandering on the unit, and that she (CNA #1) was not even thinking at the time, that it was considered a restraint. On 12/05/23, the Facility provided the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 was immediately assessed for any sign of injury or distress, none were noted, and he/she will continued to be monitored by staff, with support provided, as needed. B. 11/20//23, all residents on CNA #1's assignment were immediately assessed to ensure no other restraints were in place, were asked if there were any other concerns related to care and/or treatment provided by CNA #1. C. 11/20/23 through 12/11/23, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) completed house-wide staff re-education and training on the Facility's Restraint and Abuse Policy, which included the definition of a Restraint. D. 11/20/23 through 12/11/23, random inspections (and ongoing) conducted on all units, across all three shifts (by administrative personnel) to ensure staff understanding and compliance Restraint Policy. E. 11/20/23 through 11/24/23, audits (visual inspections) were performed by Maintenance Department Personnel, of all facility wheelchairs to make sure wheelchair brakes were adequately functioning and wheel functions were not obstructed. F. Area of concern was presented at the facility's monthly Quality Assurance Performance Improvement (QAPI) Committee Meeting, and will continue to reviewed by the committee monthly to ensure substantial compliance. G. CNA #1's employment was terminated by the facility. H. The Administrator, the Director of Nurses and/or their designee are responsible for overall compliance.

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was severely cognitively impaired and was unable to make his/her needs known to staff, the Facility failed to ensure Resident #1's right to be free from physical restraints was honored and respected by staff, when he/she was discovered at 5:40 A.M. on 05/20/23 in a fetal position (legs tucked up into chest) with the bottom corners of his/her [NAME] tied together restricting his/her ability to straighten out or move his/her legs, at will. Findings include: Review of Facility's Incident Report, dated 05/20/23, indicated Resident #1 was lying down in bed, when the covers were pulled down, Resident #1's arms were through the [NAME]'s arm holes, and it was tied behind the neck appropriately. The Report indicated Resident #1, at the same time, was observed with his/her legs curled up into the [NAME] (similar to a fetal position), and the bottom corners of the back of the [NAME] were tied (knotted) behind Resident #1's legs. The Report indicated it was unclear how this happened, but that the position left Resident #1 unable to straighten his/her legs. Review of Resident #1's medical record indicated his/her Massachusetts Health Care Proxy was activated on 10/04/21, due to cognitive impairment related to Dementia. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, indicated that Resident #1's cognitive patterns were severely impaired. The MDS indicated Resident #1 was incontinent of bowel and bladder and required extensive assistance of one to two staff persons for Activities of Daily Living. Review of Resident #1's medical record indicated there was no documentation to support he/she had been assessed for the use of, had a physician's order for the use of, or that a plan of care have been developed for the use of any authorized restraints to restrict his/her freedom of movement. Review of Resident #1's Hospice Care Plan, dated 02/09/23, indicated he/she was receiving end of life care related to Senile Degeneration of the Brain. The Hospice Care Plan interventions included the following: adjust provision of Activities of Daily Living to compensate for changing abilities; keep environment quiet and calm; keep linens clean, dry and wrinkle free; observe closely for signs of pain; and work closely with Hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. During an interview on 06/27/23 at 10:40 A.M., Certified Nurse Aide (CNA) #1 said at approximately 5:40 A.M. on 05/20/23 she entered Resident #1's room, and that although Resident #1 did not appear distressed, said there was something about Resident #1's expression that appeared unsettled or wrong. CNA #1 said she removed his/her blanket and sheet to find Resident #1 laying on his/her back, with his/her knees bent way up. CNA #1 said the bottom corners of Resident #1's [NAME] were together in an extremely tight knot, that was tied up behind him/her. CNA #1 said the [NAME] was also tied, appropriately, behind Resident #1's neck. CNA #1 said the knot at the bottom of the [NAME] confined Resident #1's legs and feet, so that the feet were up close to his/her buttocks, putting him/her in a fetal type position. CNA #1 said there was no space in the [NAME] to allow for Resident #1 to free his/her legs. CNA #1 said Resident #1 resisted care at times, and was able to move his/her arms, legs and body in a restless manner, but did not have the ability to tie or untie a [NAME] due to severe cognitive impairment. CNA #1 said she immediately showed Nurse #1 (working as a Nurse Aide that evening) and then Nurse #2 at 5:40 A.M. how a knot was tied in Resident #1's [NAME] to restrict his/her ability to straighten his/her legs. CNA #1 said after Nurse #2 left the room, and she untied Resident #1 who immediately appeared relieved and straightened his/her legs. During an interview on 06/26/23 at 11:00 A.M., Nurse #1 said while working on the unit as a Nurse Aide on 05/20/23 at 5:40 A.M., CNA #1 asked her to see Resident #1. Nurse #1 said she could not believe what she saw. Nurse #1 said Resident #1 was lying in a fetal position in bed wearing a [NAME]. Nurse #1 said the bottom of his/her [NAME] was tied together into a knot preventing Resident #1 from straightening his/her legs. Nurse #1 said Nurse #2 was also asked to immediately see Resident #1. Nurse #1 said due to Resident #1's severe cognitive impairment, he/she could not express his/her needs, was unable to comprehend the use of a call bell light, was largely nonverbal except for some nonsensical phrases spoken, and therefore would not have been able to problem solve for a solution to free his/her legs. During an interview on 06/14/23 at 12:48 P.M., Nurse #2 said on 05/20/23 at 5:40 A.M. she was told to come see Resident #1, who was in bed. Nurse #2 said Resident #1's legs were bent at the knees, the bottom of the [NAME] was tied preventing him/her from being able to straighten them. Nurse #2 said she did not know how Resident #1 could have done that to him/herself. During an interview on 06/14/23 at 09:30 A.M., and at multiple times throughout the day of the survey, the Director of Nurses said there was no authorized use of restraints at the Facility. The DON said at approximately 5:00 P.M. on 05/20/23 (approximately 11 hours after the incident occurred) Nurse #1 called her to report that CNA #1 and herself had found Resident #1 (at 5:40 A.M. on 05/20/23) in a fetal position with the bottom of his/her [NAME] tied in a knot that prevented Resident #1 from straightening his/her legs. The DON said she was unaware of any other known incidents of residents' movements being restrained by the use of a tied [NAME], as reported. Even though Resident #1 did not display a reaction of emotional distress, it can be determined that a reasonable person of intact cognitive functioning would experience harm as a result of being restrained.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was severely cognitively impaired, the Facility failed to ensure that staff implemented and followed their abuse policy related to the need to immediately report an allegation of potential abuse (use of a restraint) to the Administrator in an effort to protect other residents from potential abuse. Although Staff members on 05/20/23 at 5:40 A.M. discovered Resident #1 in a fetal position (legs tucked up into chest) with the bottom corners of his/her [NAME] tied (knotted) together (behind his/her back) restricting his/her ability to straighten out or move his/her legs at will, it was not reported to the Administrator and/or Director of Nurses until approximately 11 hours later. Findings include: Review of the Facility's Policy, titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated April 2021, indicated if resident abuse is suspected, the suspicion must be reported immediately to the administrator and to other officials in accordance to state law. Upon receiving any allegations of abuse, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Review of Resident #1's medical record indicated his/her Massachusetts Health Care Proxy was activated on 10/04/21, due to cognitive impairment related to Dementia. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, indicated that Resident #1's cognitive patterns were severely impaired. Review of Resident #1's Hospice Care Plan, dated 02/09/23, indicated he/she was receiving end of life care related to Senile Degeneration of the Brain. The Hospice Care Plan interventions included the following: adjust provision of Activities of Daily Living to compensate for changing abilities; keep environment quiet and calm; keep linens clean, dry and wrinkle free; observe closely for signs of pain; and work closely with Hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. During an interview on 06/27/23 at 10:40 A.M., Certified Nurse Aide (CNA) #1 said at approximately 5:40 A.M. on 05/20/23 she removed Resident #1's blanket and sheet to find Resident #1 laying on his/her back, with his/her knees bent way up. CNA #1 said the bottom corners of Resident #1's [NAME] were together in an extremely tight knot, and was tied up behind him/her. CNA #1 said the [NAME] was also tied, appropriately, behind Resident #1's neck. CNA #1 said the knot at the bottom of the [NAME] confined Resident #1's legs and feet, so that his/her feet were up close to his/her buttocks, putting him/her in a fetal type position. CNA #1 said there was no space in the [NAME] to allow for Resident #1 to free his/her legs. CNA #1 said she immediately showed Nurse #1 (working as a Nurse Aide that evening) and Nurse #2 at 5:40 A.M. how a knot was tied in Resident #1's [NAME] to restrict his/her ability to straighten his/her legs. CNA #1 said she untied Resident #1 who immediately appeared relieved and straightened his/her legs. During an interview on 06/26/23 at 11:00 A.M., Nurse #1 said while working on the unit as a Nurse Aide on 05/20/23 at 5:40 A.M., CNA #1 asked her to see Resident #1. Nurse #1 said Resident #1 was lying in a fetal position in bed wearing a [NAME]. Nurse #1 said the bottom of his/her [NAME] was tied together into a knot preventing Resident #1 from straightening his/her legs. Nurse #1 said Nurse #2 was also asked to immediately see Resident #1. During an interview on 06/14/23 at 12:48 P.M., Nurse #2 said on 05/20/23 at 5:40 A.M. she was told to come see Resident #1, who was in bed. Nurse #2 said Resident #1's legs were bent at the knees, and the bottom of his/her [NAME] was tied (knotted) preventing him/her from being able to straighten them. Nurse #2 said she did not report the alleged incident of abuse to a nurse supervisor, the Director of Nurses or to the Administrator during her 3:00 P.M. to 11:00 P.M. shift on 05/20/23. Nurse #2 said she was focused on returning to her medication cart to complete the medication pass and had not reported the alleged incident of abuse immediately, as required. During an interview on 06/14/23 at 09:30 A.M. and at multiple times through the day of survey, the Director of Nurses said at approximately 5:00 P.M. on 05/20/23 (approximately 11 hours after the incident occurred) Nurse #1 called her to report that CNA #1 and herself had found Resident #1 (at approximately 5:40 A.M. on 05/20/23) in a fetal position with the bottom of his/her [NAME] tied in a knot that prevented Resident #1 from straightening his/her legs. The DON said no one, including Nurse #2, notified her or the Administrator immediately after Resident #1 was found to have been restrained by the use of a tied [NAME].

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alleged to have be subjected to physical abuse via use of a restraint, after being found by in bed staff members curled up in the fetal position with his/her legs confined by his/her [NAME], that had been tied in a knot at the bottom. Although Facility administration was made aware of the allegation on 5/20/23 at approximately 5:00 P.M., the Facility failed to ensure they submitted a report to the Department of Public Health (DPH) within the required reporting timeframe, when their report regarding the allegation was not submitted to the DPH until approximately 9:00 P.M., (which was four hours after becoming aware of the allegation). Findings include: Review of the Facility's Policy, titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated April 2021, indicated if resident abuse is suspected, the suspicion must be reported immediately to the the Administrator and to other officials in accordance to state law. The Policy indicated the Administrator or individual making the allegation immediately reports his or her suspicion to the state licensing/certification agency responsible for surveying/licensing the facility. The Policy indicated that immediately is defined as within two hours of an allegation of involving abuse. Review of Resident #1's medical record indicated his/her Massachusetts Health Care Proxy was activated on 10/04/21, due to cognitive impairment related to Dementia. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, indicated that Resident #1's cognitive patterns were severely impaired. During an interview on 06/14/23 at 02:35 P.M., the Director of Nurses said that on 05/20/23 at approximately 5:00 P.M., Nurse #1 called her to report that Certified Nurse Aide (CNA) #1 and herself had found Resident #1 (at approximately 5:40 A.M. on 05/20/23) in a fetal position with the bottom of his/her [NAME] tied in a knot that prevented Resident #1 from straightening his/her legs. The DON said she notified the Administrator of the allegation of abuse at approximately 5:00 P.M. on 05/20/23. The DON said she may not have reported the allegation of abuse to the Department of Public Health within two hours of being notified. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS) indicated the facility submitted their report regarding the allegation of physical abuse at 9:18 P.M. on 05/20/23, approximately four hours after the DON had been notified of the alleged incident by Nurse #1 (at 5:00 P.M. on 05/20/23).

Based on interviews and records reviewed, for one of three sampled residents (Resident #1), who was dependent on staff to meet his/her care needs, the Facility failed to ensure Resident #1 received appropriate care and treatment related to his/her incontinence needs, when it was determined that after providing incontinence care to him/her, nursing staff had applied double briefs to Resident #1 by putting a pull-up style incontinence brief over facility incontinence brief, in an effort to inhibit his/her ability to remove it. Findings include: Review of Resident #1's clinical record indicated his/her Massachusetts Health Care Proxy was activated on 10/04/23 due to cognitive impairment related to Dementia. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/19/23, indicated that Resident #1's cognitive patterns were severely impaired. The MDS indicated Resident #1 was incontinent of bowel and bladder and required extensive assistance with one to two persons for Activities of Daily Living. Review of Resident #1's Care Plan related to Skin Integrity, dated 02/09/23, indicated he/she had the potential for pressure ulcer development related to incontinence of bowel and bladder, and decreased mobility. The Care Plan interventions included the following: follow policies and protocols for the prevention/treatment of skin breakdown; apply moisturizer barrier every shift to skin without massaging bony prominences; use of mild cleaners for peri-care/washing; document changes in skin status; and use of alternating pressure relieving/reducing mattress on bed. Review of Resident #1's Care Plan related to ADL care needs, dated 02/09/23, indicated he/she had bladder and bowel incontinence related to declining condition due to Dementia. The Care Plan interventions included to check for incontinence, and to wash, rinse, dry and change clothing as needed after incontinent episodes. Review of Resident #1's Care Plans indicated there was no documentation to support double briefing was indicated as an intervention. During an interview on 06/22/23 at 12:25 P.M., Certified Nurse Aide (CNA) #2 said sometime after supper on 05/19/23 she checked on Resident #1 to find he/she had pulled off his/her incontinent brief. CNA #2 said there was also a small amount of feces on his/her bed. CNA #2 said after incontinent care was provided, she put a clean incontinence brief on Resident #1 and then put a pull-up style brief over it. CNA #2 said she thought the pull-up brief would hold the incontinent brief in place, as it was unlikely Resident #1 would be able to remove the pull-up brief down his/her legs. CNA #2 said this was the first time she applied a double brief to a resident, and said she had not been instructed to do so by any staff. During an interview on 06/27/23 at 10:40 A.M., Certified Nurse Aide (CNA) #1 said at approximately 5:30 A.M. on 05/20/23 she entered Resident #1's room with the intention to provide incontinence care for him/her if needed. CNA #1 said she found Resident #1 to have a pull-up incontinence brief on over an incontinence brief. CNA #1 said she immediately found Nurse #2 on the Unit and showed her. CNA #1 said she removed both briefs, and applied only one incontinent brief after care was provided. Review of Nurse #2's written statement, dated 05/21/23, indicated that at 5:40 A.M. on 05/20/23 she was asked to see Resident #1. Nurse #2 indicated observing that Resident #1 was wearing two different adult briefs. During an interview on 06/28/23 at 2:45 P.M., the Director of Nurses (DON) said during a Facility investigation, CNA #2 and Nurse #1, who had worked during the 3:00 P.M. to 11:00 P.M. shift on 05/19/23, told her that during care rounds CNA #2 and Nurse Aide #1 applied a pull-up style incontinence brief over an incontinence brief on Resident #1 during first rounds, and then did it again separately, when they provided care on subsequent care rounds during the shift. The DON said CNA #2 and Nurse Aide #1 told her Resident #1 had removed his/her incontinence brief earlier during the shift and it was thought that double briefing in this manner would prevent removal of a brief. The DON said it was believed that Resident #1 was still wearing double briefs from the preceding shift (3:00 P.M. to 11:00 P.M. shift) when CNA #1 found Resident #1 wearing them during the 11:00 P.M. to 7:00 A.M. shift. The DON said it was against Facility practice to apply two briefs on any resident.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of falls and required moderate to maximum assistance of two staff members with all transfers for safety, the Facility failed to ensure staff implemented and followed interventions identified in his/her Activities of Daily Living (ADL) plan of care related to transfers. On 2/25/23, during the day shift, Certified Nurse Aide (CNA) #3 transferred Resident #1 from his/her bed to a shower chair without assistance from another staff member, Resident #1 had a near fall during the transfer, was caught by CNA #3, complained of pain after the incident, and was diagnosed two days later with a right rib fracture. Findings include: Resident #1 was admitted to the Facility in January of 2023, medical history included atrial fibrillation (irregular heat beat), that required anticoagulant therapy, congestive heart failure (CHF), diabetes, cerebral infarction (stroke) affecting the right arm and leg, severe aortic stenosis with valve replacement, high blood pressure, difficulty walking, Covid-19 infection and sacral pressure ulcer. Review of Resident #1's Care Plan related to ADL self-care performance deficit, dated as revised 2/09/23, indicated due to right sided hemiparesis (muscle weakness or partial paralysis on one side of the body, can affect arms, legs, and facial muscles) related to a stroke, edema related to CHF, non-compliance with his/her diuretic in the community, and fatigue and weakness related to Covid-19, Resident #1 was totally dependent and required two staff members to assist with transfers. Review of the Occupational Therapy Treatment Note, dated 2/23/23, indicated Resident #1 completed an exercise program at chair level, became fatigued and required maximum assist from staff for all care. The Note indicated staff demonstrated transfers and were aware a mechanical lift may be required for Resident #1 due to increased weakness. Review of the Physical Therapy Treatment Note, dated 2/24/23, indicated Resident #1 required moderate to maximum assistance of two staff members for transfers. During interview on 3/28/23 at 4:10 P.M., the Rehabilitation Director said Resident #1 was discharged from therapy on 2/24/23 due to progressive weakness and an inability to participate. The Director said at the Care Plan Meeting on 2/20/23, it was discussed with the family and nursing that Resident #1 could not transfer safely without maximum assistance of two staff members. During interview on 4/10/23 at 10:18 A.M., Certified Nurse Aide (CNA) #3 said that on 2/25/23 during the day shift, Resident #1 was on her assignment and that she was familiar with his/her care needs. CNA #3 said she was transferring Resident #1 from the bed to the shower chair when the shower chair moved backwards and Resident #1 then started falling backwards. CNA #3 said she caught Resident #1 under his/her arms, like a hug and heard a popping sound. CNA #3 said she then held one arm of the shower chair with her right hand and Resident #1 held the other shower chair arm with his/her left hand and successfully assisted him/her to a sitting position in the shower chair. CNA #3 said when she took Resident #1 back to his/her room, she asked Nurse #4 to assist her with transferring Resident #1 back to bed. CNA #3 said she reported the near fall incident to Nurse #4 at that time. CNA #3 said that during the transfer back to bed, Resident #1 complained of pain on his/her side. CNA #3 said she also reported the near fall to the 3:00 P.M. - 11:00 P.M. nurse and on 2/26/23 to the 7:00 A.M. - 3:00 P.M. nurse. CNA #3 said that at the time of this incident, Resident #1 was awake, alert and able to make his/her needs known. CNA #3 said although Resident #1 had become weaker, said she thought Resident #1 was still an assist of one staff member for transfers. During interview on 4/6/23 at 5:32 P.M., CNA #2 said each resident has a white board in their room. CNA #2 said information on the white board indicates how to care for the resident, including how to transfer a resident and how many staff are required to assist with the transfer. CNA #2 said that the Therapy Department puts the information up on the white boards in the residents rooms, and when there are any changes, the Therapy Department updates the board as well. CNA #2 said Resident #1's required an assist of two staff members for transfers. Review of a Radiology Report for a chest x-ray completed 2/27/23 for Resident #1 and compared to a previous chest x-ray of 2/23/23, concluded there was a probable nondisplaced fracture involving the right 5th rib. During interview on 3/28/23 at 5:15 P.M., Nurse #3 said she had received the chest x-ray results and reported the findings to the DNS, NP and family, 2/27/23 on the 3:00 P.M. - 11:00 P.M. shift. During interview on 3/28/23 at 11:25 A.M., the Director of Nursing Services (DNS) said she was notified of Resident #1's x-ray results regarding a fracture involving the right 5th rib on 2/27/23 on the 3:00 P.M. - 11:00 P.M. shift. The DNS said CNA #3 did not follow Resident #1's Plan of Care when she transferred Resident #1 from the bed to the shower chair without having another staff member present to assist her with the transfer.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of falls and required moderate to maximum assistance of two staff members with all transfers for safety, the Facility failed to ensure he/she was provided with the necessary level of staff assistance to maintain his/her safety in an effort to prevent incidents/accidents resulting in an injury. On 2/25/23, during the day shift, Certified Nurse Aide (CNA) #3 transferred Resident #1 from the bed to a shower chair, without another staff member present to assist her, Resident #1 had a near fall, was caught by CNA #3 who grabbed him/her under the arms, Resident #1 complained of pain after the incident, and was diagnosed with a right sided rib fracture. Findings include: The Facility Policy titled Incident Reports, undated, indicated all incident reports must include statements made by the Resident and any witnesses, new interventions implemented to prevent reoccurrence of the incident and added to the existing care plan. The Policy indicated that the Director of Nursing Services (DNS) will conduct a follow up investigation and file reports according to facility, state, and federal regulations. Resident #1 was admitted to the Facility in January of 2023, medical history included atrial fibrillation (irregular heat beat), that required anticoagulant therapy, congestive heart failure (CHF), diabetes, cerebral infarction (stroke) affecting the right arm and leg, severe aortic stenosis with valve replacement, high blood pressure, difficulty walking, Covid-19 infection and sacral pressure ulcer. Review of Resident #1's Care Plan related to Activities of Daily Living (ADL) self-care performance deficit, dated as revised 2/09/23, indicated due to right sided hemiparesis (muscle weakness or partial paralysis on one side of the body, can affect arms, legs, and facial muscles) related to a stroke, edema related to CHF, non-compliance with his/her diuretic in the community, and fatigue and weakness related to Covid-19, Resident #1 was totally dependent and required two staff members to assist with transfers. Review of the Occupational Therapy Treatment Note, dated 2/23/23, indicated Resident #1 completed an exercise program at chair level, became fatigued and required maximum assist from staff for all care. The Note indicated staff demonstrated transfers and are aware a mechanical lift may be required for Resident #1 due to increased weakness. Review of the Physical Therapy Treatment Note, dated 2/24/23, indicated Resident #1 required moderate to maximum assistance of two staff members for transfers. During interview on 3/28/23 at 4:10 P.M., the Rehabilitation Director said Resident #1 was discharged from therapy on 2/24/23 due to progressive weakness and an inability to participate. The Director said at the Care Plan Meeting on 2/20/23, it was discussed that Resident #1 required twenty-four hour care, and he/she could not transfer safely without maximum assistance of two staff members. During interview on 4/6/23 at 5:32 P.M., Certified Nurse Aide (CNA) #2 said each resident has a white board in their room. CNA #2 said information on the white board indicates how to care for the resident, including how to transfer a resident and how many staff are required to assist with the transfer. CNA #2 said that the Therapy Department puts the information up on the white boards in the residents rooms, and when there are any changes, the Therapy Department updates the board as well. CNA #2 said Resident #1's required an assist of two staff members for transfers. During interview on 4/10/23 at 10:18 A.M., Certified Nurse Aide (CNA) #3 said that on 2/25/23 during the day shift, Resident #1 was on her assignment and that she was familiar with his/her care needs. CNA #3 said she was transferring Resident #1 from the bed to the shower chair when the shower chair moved backwards and Resident #1 started falling backwards. CNA #3 said she caught Resident #1 under his/her arms, like a hug and heard a popping sound. CNA #3 said she then held one arm of the shower chair with her right hand and Resident #1 held the other shower chair arm with his/her left hand and she successfully assisted him/her to a sitting position in the shower chair. CNA #3 said she assisted Resident #1 with the shower and when she was returning him/her to his/her room, she asked Nurse #4 to assist her with transferring Resident #1 back to bed. CNA #3 said she reported the near fall to Nurse #4 at that time. CNA #3 said during the transfer back to bed, Resident #1 complained of pain on his/her side. CNA #3 said she also reported Resident #1's near fall to the 3:00 P.M. - 11:00 P.M. nurse and on 2/26/23 to the 7:00 A.M. - 3:00 P.M. nurse. CNA #3 said that at the time of the incident, Resident #1 was awake, alert and able to make his/her needs known. CNA #3 said although Resident #1 had become weaker, said she thought Resident #1 was still an assist of one staff member for transfers. During interview on 3/28/23 at 2:05 P.M., the Nurse Practitioner (NP), said she examined Resident #1 on 2/28/23 regarding rib pain resulting from a non-displaced 5th rib fracture that occurred on 2/25/23 from the incident during transfer from his/her bed to the shower chair. Review of a Radiology Report for a chest x-ray completed 2/27/23 for Resident #1 and compared to a previous chest x-ray of 2/23/23, concluded there was a probable nondisplaced fracture involving the right 5th rib. During interview on 3/28/23 at 5:15 P.M., Nurse #3 said she had received the chest x-ray results and reported the findings to the DNS, NP and Resident #1's family member on 2/27/23 during the 3:00 P.M. - 11:00 P.M. shift. During interview 3/28/23 at 1:15 P.M., Nurse #1 said incidents are documented in the computer under Risk Assessment. Nurse #1 said the nurse writes a Progress Note and the CNA writes a statement including when they last saw the resident, where and when the incident occurred and what help they gave the resident. Nurse #1 said that either the nurse that completed the Incident Report or the Unit Manager updates the residents' Care Plan. During interview 3/28/23 at 3:20 P.M., the Director of Nursing Services (DNS) said no statements from Resident #1 or staff were included with the Incident Report completed on 2/27/23 of the near fall, and resulting rib fracture. During interview on 3/28/23 at 11:25 A.M., the Director of Nursing Services (DNS) said she was notified of Resident #1's x-ray results regarding a fracture involving the right 5th rib on 2/27/23 on the 3:00 P.M. - 11:00 P.M. shift. The DNS said when CNA #3 transferred Resident #1 on 2/25/23 from the bed to the shower chair, CNA #3 should have had another staff member present to assist her with the transfer.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who experienced a near fall while being assisted into a shower chair by a staff member, and who had complained of pain to his/her right side after the incident, the Facility failed to ensure nursing notified the physician in a timely manner to obtain additional physician's orders or instructions, however, the physician was not made aware until two days after the incident occurred, at which time an order was obtained for x-rays to be obtained. Findings include: The Facility Policy titled Notification of Changes, undated, indicated that staff will make every attempt possible to notify the physician, family members, and/or legal guardian of any incident/accident, change in condition requiring provider intervention, change in physical, mental, or psychosocial status, a need to alter treatment, or a decision to transfer from the facility. Nursing staff is responsible to update the appropriate parties, including the provider, under the circumstances listed above. Nursing staff is responsible to document the communication in the nurses' notes. Resident #1 was admitted to the Facility in January of 2023, medical history included atrial fibrillation (irregular heat beat), that required anticoagulant therapy, congestive heart failure (CHF), diabetes, cerebral infarction (stroke) affecting the right arm and leg, severe aortic stenosis with valve replacement, high blood pressure, difficulty walking, Covid-19 infection and sacral pressure ulcer. During interview on 4/10/23 at 10:18 A.M., Certified Nurse Aide (CNA) #3 said that on 2/25/23 during the 7:00 A.M.- 3:00 P.M. shift Resident #1 was on her assignment and that she was familiar with his/her care needs. CNA #3 said she was transferring Resident #1 from the bed to the shower chair when the shower chair moved backwards and Resident #1 started falling backwards. CNA #3 said she caught Resident #3 under his/her arms, like a hug and heard a popping sound. CNA #3 said she then held one arm of the shower chair with her right hand and Resident #1 held the other shower chair arm with his/her left hand and he/she was successfully assisted to a sitting position in the shower chair. CNA #3 said she assisted Resident #1 with the shower and on return to his/her room, she asked Nurse #4 to assist her with transferring Resident #1 back to bed. CNA #3 said she reported the near fall to Nurse #4 at that time. CNA #3 said during the transfer back to bed, Resident #1 complained of pain on his/her right side. CNA #3 said she also reported the near fall again to the 3:00 P.M. - 11:00 P.M. nurse and on 2/26/23 to the 7:00 A.M. - 3:00 P.M. nurse. CNA #3 said that at the time of this incident, Resident #1 was awake, alert and able to make his/her needs known. Review of Resident #1's Progress Note written by Nurse #4 and dated 2/25/23, indicated Resident #1 was alert and oriented with some increased confusion over the last few days. The Note indicated Resident #1 continued with fatigue and listlessness and complained of pain in his/her back today, has a wound to the sacral area and complains of pain at that site. There was no documentation to support that Nurse #4 notified the physician or family of the near fall incident on 2/25/23, or that he/she had complained of pain. There was no documentation to support that Nurse #4 completed an Incident Report regarding Resident #1's near fall incident on 2/25/23, that occurred during his/her transfer to shower chair. The Surveyor was unable to interview Nurse #4 as she did not respond to the Departments request for an interview. During interview on 3/28/23 at 2:05 P.M., the Nurse Practitioner (NP), said that the Physician's Group was not notified on 2/25/23 of Resident #1's shower chair incident or of his/her complaints of right sided rib cage pain, until 2/27/23, and said a chest x-ray was ordered at that time. The NP said the physician should have been notified when the incident occurred. The NP said she examined Resident #1 on 2/28/23 regarding rib pain resulting from a non-displaced 5th rib fracture that occurred on 2/25/23 from the incident during transfer from bed to the shower chair. During interview on 3/28/23 at 5:15 P.M., Nurse #3 said on 2/27/23, during the 3:00 P.M. - 11:00 P.M., she had received the chest x-ray report indicating Resident #1 had a right non-displaced 5th rib fracture. Nurse #3 said she notified the Director of Nursing Services, Nurse Practitioner and Resident #1's family member of the findings. Nurse #3 said she obtained new orders for Tylenol and Lidoderm Patch and that Resident #1 had fair pain relief with the interventions. During interview 3/28/23 at 11:23 A.M., the Director of Nursing Services (DNS) said that according to Facility policy, CNA #3 should have reported the near fall to the nurse on duty 2/25/23 when the incident occurred. The DNS said that the nurse then should have reported the incident and the resident's complaint of right rib pain to the physician on 2/25/23. The DNS said an Incident Report should also have been completed by the nurse at the time of the incident.

Based on observations, record reviews, policy reviews and interviews the facility failed to 1) provide a dignified dining experience for the residents on the Dementia Care Specialty Unity (DSCU) and 2a) failed to provide a dignified experience for 1 Resident (#188) by not providing a privacy bag for a foley catheter and 2b) For Resident #188 leaving him/her without a top sheet or blanket, leaving genitals exposed, out of a total sample of 35 residents. Findings include: 1. Review of the facility policy, Quality of Life - Dignity undated, indicated the following: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. *Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis or care needs. During observation of the breakfast meal on 3/16/23 at 8:17 A.M., the following was observed: *A Certified Nursing Assistant (CNA) passed out a breakfast tray to a Resident in his/her room. The CNA walked into the Resident's room without knocking on the door. She then put the breakfast tray on the Resident's side table and did not inform the Resident what was on the breakfast tray. She walked out of the room and turned the light on, without asking the Resident if she would like it on. During observation of the lunch time meal on the DSCU on 3/17/23 at 11:55 A.M., the surveyor observed the following: *Three different staff members referred to residents as feeds while passing out the lunch trays. *There were 3 residents dining at one table. The first resident was served his/her meal at 11:59 A.M. Another resident at the table began getting agitated at 12:27 P.M., while waiting for his/her meal. The resident did not receive his/her lunch until 12:32 P.M., 33 minutes after the first resident had been served. *There were 4 residents dining at one table. The first resident was served his/her meal at 11:58 A.M. The fourth resident did not receive his/her meal until 12:26 P.M., 28 minutes later. *There were 4 residents dining at one table. The first 3 residents were served their meals by 12:02 P.M. The fourth Resident never received a meal from the kitchen and staff did not call down for a meal until 12:32 P.M. From 12:01 P.M. - 12:32 P.M., the Resident complained of being hungry and was confused why others at the table were served a meal and he/she was not. During an interview on 3/17/23 at 12:12 P.M., Nurse #3 said they try to give residents who are more anxious their meals first. During an interview on 3/17/23 at 12:59 P.M., the Administrator said the upstairs dining halls need to become more organized. The Administrator said staff should not be using terminology describing residents by their abilities and meal times should be home like with all residents sitting at the same table receiving meals at the same time. 43882 2a. Resident #188 was admitted to the facility in February 2023 with diagnoses including tracheostomy status (a surgical opening in the neck where breathing primarily occurs), multiple sclerosis, and gastrostomy (a surgical opening in the abdomen that allows for nutrition to be provided). Review of the most recent Minimum Data Set Assessment (MDS) dated , 3/14/23, indicated a Brief Interview for Mental Status score of 14 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #188 required total assistance for all hygiene tasks and required tube feedings through a gastrostomy tube. Further review indicated Resident #188 required oxygen, tracheostomy care and suctioning. During an observation on 3/15/23 at 10:23 A.M., a foley catheter bag was observed from the doorway to Resident #188's room. The foley catheter bag did not have a privacy cover. Additional observations were made on 3/16/23 at 10:01 A.M. and 3/16/23 at 1:09 P.M. of the foley catheter without a privacy cover. During an interview on 3/16/23 at 1:19 P.M., Nurse #2 said the facility uses leg bags when a resident can move around the unit and when in their room, they keep the bag out of view for privacy. During an interview on 3/16/23 at 2:27 P.M., Unit Manager #1 said privacy bags are utilized to maintain a resident's dignity. 2b. On 3/16/23 at 10:01 A.M., Resident #188 was observed lying in bed with no top sheet or blanket and a gown on pulled up to his/her abdomen exposing the genital area. He/she was visible to his/her roommate. During an interview and observation on 3/16/23 at 1:13 P.M., Resident #188 was observed lying in bed with a gown on with no top sheet or blanket. Resident #188 said he/she wanted a blanket and did not prefer to be uncovered. During an interview on 3/16/23 at 1:19 P.M., Nurse #2 said residents should never be exposed.

Based on observations, record reviews and interviews, the facility failed to 1) develop a care plan for suicidal ideation for 1 Resident (#16), 2) failed to implement a physician order to off load heels for 1 Resident (#118), 3) failed to implement a physician order for ace wraps for 1 Resident (#239) and 4) failed to implement a physician order to obtain a urine culture for 2 Residents (#3 and #88) out of a total sample of 35 residents. Findings include: 1. Resident #16 was admitted to the facility in September 2021 with diagnoses including anxiety, depression, and dementia without behavioral disturbances. Review of Resident #16's most recent Minimum Data Set, dated dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15, indicating he/she has moderate cognitive impairment. The MDS also indicated Resident #16 has had recent feelings of feeling down, depressed and hopeless. On 3/16/23 at 8:53 A.M., Resident #16 was observed yelling out on the unit at staff. While yelling, the Resident made the comments I'm going to escape and I will kill myself if I have to, and I'll jump out the window. The Resident also said he/she would rather die than be in the facility. The Resident was yelling and agitated for 20 minutes. Review of the hospital admission paperwork, dated 1/11/23, indicated Resident #16 was admitted to the hospital from the facility with increased agitation, disruptive behavior (yelling, throwing things, etc.) and suicidality. Review of Resident #16's care plans failed to indicate a care plan that included interventions for the Resident's suicidal ideation. During interviews on 3/16/23 at 8:57 A.M., and 3/17/23 at 9:05 A.M., Unit Manager #1 said Resident #16 has become increasingly agitated over the past several months and has had involuntary admissions to the hospital a few times. Unit Manager #2 said Resident #16 will often make suicidal comments about his/her desire to die. Unit Manager #1 said social services typically put in care plans for psychiatric needs as well as suicidal ideation care plans and said Resident #16 did not have a suicidal ideation care plan and should have one. During an interview on 3/17/23 at 10:17 A.M., the Social Services Director said any resident with a history of or active suicidal ideation should have a suicidal ideation care plan. 2. Resident #118 was admitted in March 2022 with diagnoses including stroke and diabetes. Review of Resident #118's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of a 2 out of a possible 15, indicating he/she has severe cognitive impairment. The MDS also indicated Resident #118 requires extensive assistance from staff for bed mobility tasks. On 3/16/23 at 9:18 A.M., Resident was observed lying in bed. Both heels were lying directly on the bed and not offloaded. On 3/17/23 at 8:03 A.M., Resident was observed lying in bed. Both heels were lying directly on the bed and not offloaded. On 3/17/23 at 11:55 A.M., Resident was observed lying in bed. Both heels were lying directly on the bed and not offloaded. Review of Resident #118's physician orders indicated an order for the Resident's heels to be offloaded. During an interview on 3/17/23 at 2:53 P.M., the Director of Nursing said she expects all written orders to be followed. 41019 3. Resident #239 was admitted in 03/2023 with diagnoses including localized edema. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #239 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the physician's orders indicated that an order was initiated on 3/10/23 for ace wrap to left lower extremity daily prior to getting out of bed. Review of the behavior tracking documentation does not indicate that Resident #239 has any behaviors. During an observation on 3/15/23 at 7:54 A.M., Resident #239 was not wearing ACE wraps on his/her left lower extremity. During an observation on 3/17/23 at 11:26 A.M., Resident #239 was out of bed and not wearing ACE wraps on his/her left lower extremity. During an interview on 3/17/23 at 11:26 A.M., Resident #239 said that he/she has not had any ACE wraps on since admission. During an interview on 3/17/23 at 2:49 P.M., the Director of Nursing said that if there was an order for ACE wraps then it should have been followed. 43882 4a. Resident #3 was admitted to the facility in June 2021 with diagnoses including peripheral vascular disease, overactive bladder and hemiplegia/hemiparesis following cerebral infarction. Review of the most recent Minimum Data Set Assessment (MDS) dated , 2/16/23, indicated a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated Resident #3 required extensive assistance for toilet use. Review of Resident #3's medical record indicated the following: -Physician Order dated 3/7/23, order for Urinalysis with Culture and Sensitivity due to leukocytosis rule out acute cystitis. -Further review of the medical record failed to indicate results for the ordered Urinalysis or documentation indicating staff were unable to obtain the specimen During an interview on 3/17/23 at 2:22 P.M., Unit Manager #1 said when a resident has an order for a Urinalysis the expectation is to try to obtain it within three days. Unit Manager #1 said the expectation would be for the nursing staff to document when the lab is unable to be obtained. During an interview on 3/17/23 at 2:50 P.M., the Director of Nursing said the expectation for a physician ordered Urinalysis would be for it to be completed as soon as possible or documentation when it cannot be obtained. 4b. Resident #88 was admitted to the facility in November 2021 with diagnoses including, dementia, benign prostatic hyperplasia without lower urinary tract symptoms, and acquired absence of kidney. Review of the most recent Minimum Data Set assessment dated , 12/29/22, indicated Brief Interview for Mental Status score of 11 out of a possible 15 indicating moderate cognitive impairment. Review of Resident #88's medical record indicated the following: -A Care Plan revision date 1/31/22 with a focus on bladder incontinence with interventions for monitor/document signs and symptoms of UTI (Urinary Tract Infection). -A nursing progress noted dated 3/9/23 indicated Resident #88 had increased behaviors and a question of UTI when assisted to bed. -A physician order dated 3/10/23 to please obtain Urinalysis with culture and sensitivity. -Further review of the medical record failed to indicate documentation that a urinalysis had been obtained or had been attempted to be obtained. During an interview on 3/17/23 at 2:22 P.M., Unit Manager #1 said when a resident has an order for a Urinalysis the expectation is to try to obtain it within three days. Unit Manager #1 said the expectation would be for the nursing staff to document when the specimen is unable to be obtained. During an interview on 3/17/23 at 2:50 P.M., the Director of Nursing said the expectation for a physician ordered Urinalysis would be to be done as soon as possible and documentation completed when it cannot be obtained.

Based on observation, interview and policy review, the facility failed to 1) properly store food items to prevent the risk of foodborne illness and 2) follow proper food handling practices to prevent the risk foodborne illness and contamination. Findings include: Review of the facility policy titled Food Storage, undated, indicated the following: *Leftover food will be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. Leftover food must be used within 72 hours or discarded. *Refrigerated food storage: Cooked foods will be stored above raw foods to prevent contamination. Raw animal foods must be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers. Review of the facility policy titled General Food Preparation and Handling, undated, indicated the following: *Bare hands must never touch ready to eat raw food directly. Disposable gloves are a single use item and must be discarded after each use. Employees must wash hands prior to putting gloves on and after removing gloves. 1) During the initial walk through of the kitchen on 3/15/23 at 6:58 A.M., the surveyor observed the following: *A container labeled egg salad with an expiration date of 3/13/23 *A container labeled tuna salad with an expiration date of 3/13/23 *A container labeled pineapple with an expiration date of 3/11/23 *A container labeled ham with an expiration date of 3/9/23 *A container labeled turkey with an expiration date of 3/9/23. *A container labeled apple muffins containing ready to eat food that was stored on the raw meat defrosting rack below a box of raw ground beef. During observation of the 2 South Kitchenette on 3/17/23 at 6:47 A.M., the following was observed: *Wheat bread with the expiration date of 2/27/23. *A tuna salad sandwich dated 3/6/23-3/8/23. *Cranberry juice container in the refrigerator, undated, and sticking to the shelf. *Soup single boxes, not labeled or dated. *A package of cookies on the cabinet opened and not dated or labeled. During an interview on 3/15/23 at 7:10 A.M., the Food Service Director said food should be discarded by the written expiration date and that ready to eat foods should not be stored with raw meat products. 2) During the follow up visit to the kitchen on 3/17/23 at 11:46 A.M., the surveyor observed the following during the lunch service tray line: *The cook was observed grabbing the handle of the walk-in freezer with bare hands and entering it to grab food product, she then proceeded to touch the drying rack for the plate lids. She then proceeded to put on a disposable glove on her right hand without washing her hands prior and began cooking a veggie burger. The cook then entered the walk-in freezer with the same glove on her right hand and exited with a raw beef patty, removed the glove, did not wash her hands and began cooking the beef patty. The cook then put on a new glove on her right hand without washing her hands and grabbed ready-to-eat hamburger buns from the package with the gloved hand. She then grabbed ready-to-eat cheese with the same gloved hand and put it on a veggie burger that was cooking. The cook then removed her glove without washing her hands and left the kitchen to open a meal cart in the hallway. With bare hands, the cook then touched a pile of oven mitts, opened the reach-in refrigerator, touched the drying rack for the meal lids and began setting up a meal tray. The cook then put on a glove on her right hand without washing her hands and grabbed a ready-to-eat hamburger bun from the packaging with the gloved hand. During an interview on 3/17/23 at 1:57 P.M., the Food Service Director said her expectations are for staff to wash their hands when donning and doffing gloves as well as after they return from leaving the kitchen.

Based on observation and interviews, the facility failed to appropriately wear Personal Protective Equipment (PPE) to prevent the spread of infection on 2 out of 4 units. Findings include: Throughout the days of survey, the following was observed: On 3/15/23 at 7:30 A.M., two nurses were observed at the 2 North nursing station. One nurse was wearing a mask on her chin, not covering her mouth or nose and the second nurse was wearing her mask below her nose. There were several residents in the area. On 3/15/23 at 12:29 P.M., a Certified Nursing Assistant (CNA) was eating at the 2 South nursing station while talking with a resident. Her mask was on her chin. On 3/15/23 at 12:44 P.M. a nurse was sitting at the 2 North nursing station with her mask below her nose. There were several residents in the area. On 3/16/23 at 12:14 P.M., a nurse was standing at the 2 North nursing station not wearing a mask. There were several residents in the area. On 3/16/23 at 2:35 P.M., an activity assistant was in the 2 South activity room with residents and her mask was on her chin, below her mouth and nose. During an interview on 3/16/23 at 1:30 P.M., the Infection Preventionist said she completes in-services for PPE when needed. The IP said staff should be wearing when in patient areas and the masks should be covering both the nose and mouth area.

Based on observation, record review, and interview, the facility failed to implement effective or new interventions to prevent falls and complete thorough investigations following falls for 6 Residents (#27, #52, #50, #77, #2, #53) out of a total sample of 33 residents. Findings include: Review of the facility policy titled Fall Prevention Policy, dated 01/2021, indicated the following: - Fall Review: The weekly sub-risk meeting meets once weekly to discuss most recent falls, and ensures current interventions in place are appropriate, and follow up measures have been taken. - Upon admission to the facility, nursing will complete a fall risk assessment in the electronic medical record. - Nurse in charge will determine the most appropriate fall interventions for the next 72 hours. - IDC (Interdisciplinary Care team) will determine most appropriate and patient-specific interventions for on-going fall prevention. - The resident is followed at the weekly risk meeting for 4 weeks following admission. - When an incident occurs, it will be reported to the nurse immediately - The resident will be identified as a high fall risk on the CNA kardex and assignment sheet for 72 hours or longer. 1.) Resident #27 was admitted to the facility in August 2021, and had diagnoses that included dementia and [CONDITION(S)]. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/13/22, revealed that on the Brief Interview for Mental Status (BIMS) exam, Resident #27 scored a 2 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #27 had no behaviors and required 1-2 person physical assistance from staff for transfers and ambulation. Resident #27 had a falls care plan initiated on 7/31/21 that indicated Resident #27 is high risk for falls related to confusion, deconditioning, gait/balance problems, [CONDITION(S)], incontinence, poor communication/comprehension, unaware of safety needs. There were 3 interventions listed on the care plan: (1.) anticipate and meet resident needs; (2.) be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; and (3.) follow facility fall protocol. Review of the medical record on 3/23/22 at 2:18 P.M., indicated Resident #27 had 14 falls between August 2021 and March 2022. The following falls investigations, provided by the facility, failed to indicate a thorough investigation was conducted and/or that the care plan was reviewed/updated following a fall: * On 8/2/21, Resident #27 had an unwitnessed fall in his/her bedroom. - Review of the falls care plan indicated that although a falls care plan was initiated on 7/31/21, staff failed to review the care plan on 8/2/21, or implement any new interventions, when interventions in place were ineffective. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 8/3/21, Resident #27 had an unwitnessed fall in the hallway, 24 hours after having a fall, on 8/2/21. - Review of the falls report indicated Resident #27 sustained a fracture of the trochantur (thigh bone) on 8/3/21. - Review of the falls care plan indicated that although a falls care plan was initiated on 7/31/21, staff failed to review the care plan on 8/3/21 following 2 falls within 24 hours, with the second resulting in a thigh fracture. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 8/23/21, Resident #27 had an unwitnessed fall in the hallway. -Review of the falls report failed to indicate an investigation was conducted; There were no statements collected from staff, that were working on the unit at the time of the fall. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following an unwitnessed fall in the hallway. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 8/25/21, Resident #27 had an unwitnessed fall in the hallway. -Review of the falls report indicated that the post incident interdisciplinary team review attached to the report was blank. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following the second unwitnessed fall in the hallway in a two day time period. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 8/28/21, Resident #27 had an unwitnessed fall in the hallway. -Review of the information provided indicated a falls report was not completed. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following the third unwitnessed fall in the hallway in a 5-day time period. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 9/2/21, Resident #27 had an unwitnessed fall, out of a recliner, in the bedroom. -Review of the falls report indicated that the post incident interdisciplinary team review attached to the report was blank. * On 9/10/21, Resident #27 had an unwitnessed fall, out of a recliner, in the hallway. -Review of the falls report indicated that the post incident interdisciplinary team review attached to the report was blank. -Resident #27 re-opened an old skin tear on his/her knee at the time of the fall. * On 10/14/21, Resident #27 had an unwitnessed fall, out of a recliner, in the bedroom. -Review of the falls report failed to indicate witness statements from staff working on the unit at the time of the fall were obtained. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following an unwitnessed fall in the bedroom. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 10/17/21, Resident #27 had an unwitnessed fall, out of a recliner chair, in the hallway. -Review of the falls report indicated that the post incident interdisciplinary team review attached to the report was blank aside from one written statement Pt (patient) requires 1:1 at all times. - Review of the care plan failed to indicate any new interventions were put in place, including the 1:1 at all times. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 10/29/21, Resident #27 had an unwitnessed fall, out of a recliner, in the bedroom. -Review of the falls report indicated that the post incident interdisciplinary team review attached to the report was blank. * On 1/1/22, Resident #27 had an unwitnessed fall in the bedroom. - Review of the falls report indicated Resident #27 required to be sent to the hospital following the fall, however there was no indication if the resident sustained any injury. -Review of the falls report failed to indicate witness statements, from staff working on the unit at the time of the fall, were obtained. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following an unwitnessed fall in the bedroom and hospitalization . - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 2/9/22, Resident #27 had a witnessed fall out of a recliner chair. -Review of the falls report failed to indicate witness statements, from staff working on the unit at the time of the fall, were obtained. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following an unwitnessed fall in the bedroom resulting in a need to be sent to the hospital. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 2/15/22, Resident #27 had an unwitnessed fall in the bedroom. - Review of the falls report indicated Resident #27 was to be sent to the hospital following the fall, due to an injury to the top of the scalp. -Review of the falls report failed to indicate witness statements, from staff working on the unit at the time of the fall, were obtained. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following an unwitnessed fall in the bedroom resulting in a need to be sent to the hospital. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. During an interview with Resident #27's Certified Nursing Assistant (CNA) #2 on 3/24/22 at 10:43 A.M., she said that Resident #27 requires 2 staff to ambulate him/her but that Resident #27 was always swinging his/her legs over the side of the recliner chair, until he/she manages to get up and out of the recliner chair, and then Resident #27 falls. During an interview with Resident #27's Nurse (#1) on 3/24/22 at 11:03 A.M., she said that Resident #27 was always trying to get out of his/her chair and had sustained many falls. Nurse #1 said she had been instructed to call Resident #27's family if he/she was agitated and needed 1:1 to prevent falls but that she had never called them. During an interview with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) on 3/25/22 at 11:51 A.M., they said that there are no falls risk meetings taking place. The ADON said that fall risk assessment should be completed for all residents on admission by the MDS nurse or admitting nurse and interventions should be put on the care plan as appropriate. If a fall occurs, the expectation is that the staff would try to understand why the fall took place and update the care plan with a new intervention. The Resident would then be followed at the weekly fall risk meeting. As part of the fall investigation report, all staff that were working at the time of the fall should be interviewed for witness statements. The NHA said that the facility's day to day operations overshadowed the facility focusing on falls, which he now realized they would have to do. Additionally, the NHA said that although they had not been able to stop Resident #27 from falling, that he/she was in a recliner chair and that slowed down Resident #27's ability to get up, delayed the opportunity to fall and gave staff the opportunity to see he/she had a need and address the need, thereby possibly preventing a fall. 2.) Resident #52 was admitted to the facility in September 2021, and had diagnoses that included dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/30/21, revealed that on the Brief Interview for Mental Status (BIMS) exam, Resident #52 scored a 1 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #52 had no behaviors and required extensive to total assistance from staff for all Activities of Daily Living (ADLs). Review of the record on 3/23/22 at 2:18 P.M., indicated Resident #52 had 9 falls between November 2021 and March 2022. The falls investigations, provided by the facility, varied in content and the following reports failed to indicate a thorough investigation was conducted and/or that the care plan was reviewed / updated following a fall: * On 11/2/21, Resident #52 had a witnessed fall in the hallway. - Review of the falls report indicated Resident #52 complained of temple and left shoulder pain and was sent to the emergency room for evaluation. -Review of the falls report failed to indicate witness statements, from staff working on the unit at the time of the fall, were obtained. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following an witnessed fall requiring hospitalization . - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 11/7/21, Resident #52 had an unwitnessed fall in the bedroom. - Review of the falls report indicated Resident #52 was found on the floor in the bedroom by his/her roommate. -Review of the falls report failed to indicate witness statements from staff, working on the unit at the time of the fall, were obtained. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 11/26/21, Resident #52 had a witnessed fall in the hallway. -Review of the falls report failed to indicate witness statements, from staff working on the unit at the time of the fall, were obtained. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following an witnessed fall requiring hospitalization . - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 12/5/21 Resident #52 had an unwitnessed fall, out of a recliner chair, in the hallway, resulting in the chair flipping over. Resident #52 struck his/her head during the fall and required a transfer to the hospital for evaluation. -Review of the falls report indicated that the post incident interdisciplinary team review and the fall review worksheet attached to the report was blank. * On 1/10/22, Resident #52 had a witnessed fall in the hallway. -Review of the falls report failed to indicate witness statements, from staff working on the unit at the time of the fall, were obtained. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 1/31/22, Resident #52 had an unwitnessed fall in the bedroom. - Review of the falls report indicated Resident #52 was found face down, with his/her chin on a mattress and feet on the floor. Resident #52 complained of shoulder pain and was sent to the hospital. -Review of the falls report failed to indicate witness statements, from staff working on the unit at the time of the fall, were obtained. - Review of the care plan failed to indicate the falls care plan was reviewed and failed to indicate any new interventions were put in place, following a fall that resulted in hospitalization . - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 2/14/22, Resident #52 had an unwitnessed fall in the bedroom. - Review of the falls report indicated Resident #52 was found on the floor in the bedroom. -Review of the falls report failed to indicate witness statements from staff working on the unit at the time of the fall were obtained. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 2/27/22, Resident #52 had a witnessed fall in the hallway. - Review of the falls report indicated Resident #52 fell to the floor from a chair in the hallway. -Review of the falls report failed to indicate witness statements, from staff working on the unit at the time of the fall, were obtained. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. * On 3/10/22, Resident #52 had an unwitnessed fall in the bedroom. - Review of the falls report indicated Resident #52 was found on the floor in the bedroom. -Review of the falls report failed to indicate witness statements from staff working on the unit at the time of the fall were obtained. - The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. During an interview with the Assistant Director of Nursing (ADON) on 3/23/22 at 1:49 P.M., she said that there had been no nurse unit manager and no resident at risk meetings being held at the facility since early December 2021. During an interview with Resident #52's Certified Nursing Assistant (CNA) #2 on 3/24/22 at 10:45 A.M., she said that Resident #52 requires total care from staff and falls frequently trying to get up unassisted. During an interview with Resident #52's Nurse (#1) on 3/24/22 at 11:05 A.M., she said that Resident #52 was a high fall risk and required close supervision at all times from staff. During an interview with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) on 3/25/22 at 11:51 A.M., they said that there are no falls risk meetings taking place. The ADON said that fall risk assessment should be completed for all residents on admission by the MDS nurse or admitting nurse and interventions should be put on the care plan as appropriate. If a fall occurs, the expectation is that the staff would try to understand why the fall took place and update the care plan with a new intervention. The Resident would then be followed at the weekly fall risk meeting. As part of the fall investigation report, all staff that were working at the time of the fall should be interviewed for witness statements. The NHA said that the facility's day to day operations overshadowed the facility focusing on falls, which he now realized they would have to do. 3. Resident #50 was admitted in 07/2021, with diagnoses including dysphagia and dementia. Review of the Minimum Data Set (MDS), dated [DATE], revealed that Resident #50 scored a 1 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS further indicated that Resident #50 required two-person assist with transfers and bed mobility. Review of the care plan for Resident #50 indicated that he/she was at risk for falls secondary to past medical history, use of [CONDITION(S)] medication, lack of safety awareness, and incontinence related to dementia. The care plan was initiated on 7/25/2021. The following interventions, in chronological order, are: - Follow facility fall protocol (7/25/21) - Provide support to Resident #50 and ensure needs are met (8/31/21) - Assist Resident #50 to toilet and maintain him/her in a monitored area when he/she appears to be restless (9/8/21) - Assist and encourage to toilet as needed (10/17/21) - Offer snack after meals, activities as needed. (10/17/21) - Be sure the call light is in reach, encourage Resident #50 to utilize when needed for assistance (10/24/21) - Perimeter mattress to the bed to define space. (1/24/22) Review of the fall incident reports indicated the following: . -On 12/17/21, Resident #50 had a fall out of his/her wheelchair onto the floor in the dining room during activities. Review of the fall incident report and care plan did not indicate that any new interventions were put in place to prevent future falls, but that close supervision was an intervention already in place. The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. -On 12/28/21, Resident #50 had a fall from his/her wheelchair in the dining room during activities. Review of the incident report and care plan do not indicate that any interventions were implemented to prevent a future fall. The fall incident report indicates that interventions already in place prior include close supervision and non-skid socks. The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. -On 1/8/22, Resident #50 had a fall in the dining room during activities. Resident #50 was sent to the emergency room for evaluation. Review of the incident report and care plan do not indicated that any interventions were implemented to prevent falls. On 1/24/22, 14 days later, a perimeter mattress was put in place. -On 2/14/22, Resident #50 had a fall in the hallway as the Activity staff was attempting to transfer Resident #50. No new interventions were put in place at that time and the care plan was not updated or revised. The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. -On 2/21/22, Resident #50 had a fall in the hallway. Resident #50 was attempting to walk in the hallway and fell and hit his/her head. Review of the incident report and care plan do not indicate that any interventions were put in place at that time and there was no indication that the care plan was not updated, reviewed, or revised. During an interview on 3/24/22 at 10:02 A.M., Activities Assistant #1 said that Resident #50 has fallen four times during activities and that she had a lot going on at once when they occurred. Activities Assistant #1 said that she is generally the only one in the activities room during activities and there are no CNA's to help with supervision in the room. Activities Assistant #1 said she was not involved in fall risk meetings. During an interview on 3/25/22 at 12:00 P.M., when asked if the intervention of close supervision remained appropriate after multiple unwitnessed falls in the activities room, the ADON and NHA agreed the intervention should have been reviewed and updated. During an interview with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) on 3/25/22 at 11:51 A.M., they said that there are no falls risk meetings taking place. If a fall occurs, the expectation is that the staff would try to understand why the fall took place and update the care plan with a new intervention. The Resident would then be followed at the weekly fall risk meeting. 4. Resident #77 was admitted in 05/2021 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], revealed that Resident #77 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of the care plan for Resident #77 indicated that Resident #77 is at a high risk for falls related to poor coordination and muscle weakness, decrease mobility, fall history, incontinence, and use of [CONDITION(S)] medications (initiated 5/23/21). The interventions on the care plan are as follows: - Follow facility fall protocol (5/23/21) - Monitor and ensure Resident #77 is wearing appropriate footwear. If he/she refuses to wear shoes, offer non-skid socks as an alternative ( 8/31/21) - Anticipate and meet all of Resident #77's needs (8/31/21) - Encourage Resident #77 to participate in activities that promote exercise, physical activity for strengthening and improved mobility as needed (8/31/21) - In-services provided to staff: keep bed locked and to appropriate bed height (9/7/21) - New cushion to help to support her back posture on wheelchair (9/28/21) - Assist to remove bed side table when not in use (10/11/21) - Encourage and assist Resident #77 to lock wheelchair during transfer or self positioning to prevent a fall (9/1/21) - Cushion to the back of wheel chair for support (9/28/21) - Floor mat to the side of the bed when resident is in the bed, therapy screen put in for evaluation and treat as needed (1/26/22) Review of the fall incident reports indicated that Resident #77 had a fall on 6/1/21 and was found on the floor in his/her bathroom with no injuries and was moved back to bed. Review of the clinical record does not indicate that there had been any new interventions implemented or that the care plan has been reviewed/revised to prevent a future fall. The only intervention on the care plan prior to the fall was to follow facility fall protocol, which was implemented on 5/23/21. Review of the fall incident reports indicated that Resident #77 had a fall on 6/6/21 and was found on the floor in his/her room. There is no indication from the fall incident report and care plan that any new interventions had been implemented to prevent a future fall. The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. Review of the fall incident reports indicated that Resident #77 had a fall on 6/15/21 and was found on the floor after attempting to self transfer. Resident #77 was sent to the emergency room . The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. Review of the Incident Report form, dated 6/17/21, indicated that Resident #77 had sustained a fracture of the left clavicle as well as an L1 compression fracture from the fall that occurred on 6/15/21. Resident #77 returned from the hospital on 6/18/21. During an interview with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) on 3/25/22 at 11:51 A.M., they said that there are no falls risk meetings taking place. The ADON said that fall risk assessment should be completed for all residents on admission by the MDS nurse or admitting nurse and interventions should be put on the care plan as appropriate. If a fall occurs, the expectation is that the staff would try to understand why the fall took place and update the care plan with a new intervention. The Resident would then be followed at the weekly fall risk meeting. As part of the fall investigation report, all staff that were working at the time of the fall should be interviewed for witness statements. The NHA said that the facility's day to day operations overshadowed the facility focusing on falls, which he now realized they would have to do. 5. Resident #2 was admitted in 09/2021 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], revealed that Resident #2 scored a 6 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated, Resident #2 required one person physical assist with transfers, walking in room, and locomotion on the unit. Review of the care plan for Resident #2 indicated that Resident #2 was at risk for falls related to impaired cognitive status due to vascular dementia and daily use of [CONDITION(S)] medications (initiated 9/15/21). The interventions are as follows: - Anticipate and meet the resident's needs (9/15/21) - Physical Therapy evaluate and treat as ordered or as needed (9/15/21) - Be sure Resident #2's call light is within reach and encourage resident to use it for assistance as needed. (9/15/21) - Encourage Resident #2 to participate in activities that promote exercise, physical activity for strengthening and improved mobility (9/15/21) - Follow facility fall protocol (9/15/21) - Resident #2 needs activities that minimize the potential for falls while providing diversion and distraction (9/15/21) - Orthostatic Blood Pressure x 3 days (11/18/21) - The resident was sent to the emergency room status post fall for eval and treat, with medical work up. Therapy evaluation put in for the resident to have her seating evaluated (1/25/22) Review of the fall incident report, dated 1/15/22, indicated that Resident #2 was found on the floor in the hallway. The incident report and care plan do not indicate that any interventions were implemented to prevent a future fall. The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. Review of the incident report, dated 1/25/22, indicated that Resident #2 was found lying in the hallway with blood around his/her head after a head strike. Resident #2 was sent to the hospital and had sustained a 1.5 centimeter laceration. Review of the care plan indicated that, on 1/25/22, a therapy evaluation was put in post fall. During an interview with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) on 3/25/22 at 11:51 A.M., they said that there are no falls risk meetings taking place. The ADON said that fall risk assessment should be completed for all residents on admission by the MDS nurse or admitting nurse and interventions should be put on the care plan as appropriate. If a fall occurs, the expectation is that the staff would try to understand why the fall took place and update the care plan with a new intervention. The Resident would then be followed at the weekly fall risk meeting. As part of the fall investigation report, all staff that were working at the time of the fall should be interviewed for witness statements. The NHA said that the facility's day to day operations overshadowed the facility focusing on falls, which he now realized they would have to do. 6. Resident #53 was admitted in 09/2021 with diagnoses including hypertension and cognitive impairment. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #53 scored at 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Resident #53 requires extensive assist of two people for all activities of daily living. Review of the falls care plan indicated that Resident #53 had a right hip and humerus fracture related to a fall (initiated 10/5/21). The interventions are as follows: (all initiated on 10/5/21) - Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests. - Follow doctor orders for weight bearing status. - Modify environment as needed to meet current needs: non-slip surface for bath/shower, bed in lowest position with wheels locked, floors that are even and free from spills, clutter, adequate, glare-free light. - Monitor/document pain on a scale of 1/10 - Monitor/document/report as needed, signs and symptoms - Monitor/evaluate/provide with/monitor use of adaptive devices as needed: fracture pan, gait belt, abduction pillow, walker, wheelchair, elevated toilet seat - Physical therapy, Occupational therapy evaluation and treatment per orders. Review of the fall incident report, dated 12/28/21, indicated that Resident #53 had fallen in his/her room on the floor. Review of the incident report and care plan did not indicate that any interventions were implemented/updated to prevent a future fall. The fall incident report did not contain any witness statements. The facility did not provide any indication that the fall and appropriate interventions were reviewed, as stated in the facility fall protocol. Review of the fall incident report, dated 2/2/22, indicated that Resident #53 had an unwitnessed fall and hit his/her head. Review of the incident report and care plan did not indicate that any interventions were implemented, updated, or reviewed per facility policy. During an interview with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) on 3/25/22 at 11:51 A.M., they said that there are no falls risk meetings taking place. The ADON said that fall risk assessment should be completed for all residents on admission by the MDS nurse or admitting nurse and interventions should be put on the care plan as appropriate. If a fall occurs, the expectation is that the staff would try to understand why the fall took place and update the care plan with a new intervention. The Resident would then be followed at the weekly fall risk meeting. As part of the fall investigation report, al [TRUNCATED]

Based on observation, interview, and record review, the facility failed to prevent neglect for 1 Resident (#77), by leaving the Resident on a bed pan for over an hour without access to a call light, out of a total sample of 33 residents. Findings include: Resident #77 was admitted in 05/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #77 scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS further indicated, Resident #77 is a two-person extensive assist with bed mobility and one person physical assist with transfers. Review of the facility policy titled Abuse Policy and Procedures, dated 08/2017, indicated the following: -It is the policy of Penacook Place that each resident has the right to be free from verbal, sexual, physical and mental abuse, neglect, exploitation, involuntary seclusion, misappropriation of their property. -Neglect: Failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. -At risk: Residents most at risk of neglect and abuse (i.e. residents who have dementia). -Signs/symptoms of abuse/neglect including, but no limited to: -Inadequate provision of care - Left alone- no supervision During an observation on 3/22/22 at 8:15 A.M., the surveyors entered Resident #77's room and discovered Resident #77 leaning slightly toward his/her right side with a bed pan underneath his/her buttocks, exposed. During an interview on 3/22/22 at 8:15 A.M., Resident #77 said that he/she was left on the bed pan and was very uncomfortable. Resident #77 said that he/she had been calling for help, but no one had come in to remove the bed pan. Resident #77 could not reach the call light that was attached to the mattress behind Resident #77's back. During an interview on 3/22/22 at 8:20 A.M., Certified Nursing Assistant (CNA) #3 said that the bed pan must have been left by the 11-7 shift because he had not yet been in Resident #77's room that morning, and was the CNA assigned to Resident #77. CNA #3 removed the bed pan and said that the area where the bed pan was touching Resident #77's skin was reddened; the bed pan was full of urine. During an interview on 3/22/22 at 11:03 A.M., the Administrator said he was notified of the incident at 8:45 A.M. Review of the incident report indicated that the CNA on the 11-7 shift had put Resident #77 on the bed pan at 6:55 A.M., indicating that Resident #77 was on the bed pan for 1 hour and 20 minutes before being discovered by the surveyors.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure staff administered medications as ordered by the Physician, when the medications [MEDICATION NAME] (diuretic) and Potassium (supplement) were accidentally discontinued from Resident #1's electronic medical record (eMAR) for a period of one month, and as a result he/she experienced a change in condition requiring hospitalization . Findings include: The Facility's Medication Error Report, dated 1/11/20, indicated that Resident #1's [MEDICATION NAME] and Potassium were discontinued from his/her eMAR on 12/13/19 because his/her previous primary care physician was no longer [MEDICATION NAME] and the orders were still in his name. The Report indicated the orders were not re-entered under the new primary care physician, in error. The Facility's Incident Narrative, dated 1/15/20, indicated that on 1/11/20, Resident #1 experienced a change in condition including shortness of breath, was transferred to the Hospital Emergency Department for evaluation, and was admitted with acute on chronic [MEDICAL CONDITION]. The Narrative indicated it was identified that Resident #1's [MEDICATION NAME] and Potassium were accidentally discontinued from his/her eMAR on 12/13/19. Review of Resident #1's medical record including the eMAR indicated, there was no documentation to support that he/she was administered his/her [MEDICATION NAME] and Potassium medications after 12/13/19. The Nurse Progress Note, dated 1/10/20, indicated Resident #1 complained of not feeling too good, but was unable to be specific. The Nurse Progress Note, dated 1/11/20, timed 2:04 P.M., indicated Resident #1's face was dusky, pale, cool to the touch, and his/her right hand and forearm were [MEDICAL CONDITION] (swollen). The Note indicated Resident #1's oxygen saturation (a measurement of the percentage of oxygen in the blood) was low at 84%, (normal range of 92-100%) he/she was wheezing, had diminished lung sounds, his/her abdomen was distended and firm, and that the on-call Nurse Practitioner was notified. The Nurse Progress Note, dated 1/11/20, timed 4:59 P.M., indicated Resident #1's condition worsened and an order was obtained to transfer him/her to the Hospital Emergency Department for evaluation. The Hospital History and Physical, dated 1/11/20, indicated Resident #1 was admitted to the hospital with [REDACTED]. During an interview on 1/21/20 at 3:58 P.M., Nurse #1 said that on 12/13/19, she noticed that Resident #1's [MEDICATION NAME] and Potassium had not been refilled by the Pharmacy, and said that when she spoke to someone at the Pharmacy, they explained that those medications were still ordered under Resident #1's previous Physician, who was no longer [MEDICATION NAME], and would need to be changed in the eMAR to the new Physician. Nurse #1 said she removed the [MEDICATION NAME] and Potassium orders from the eMAR, and thought she re-entered them correctly under the new Physician. Nurse #1 said she was made aware on 1/11/20 that the orders had not been properly entered, and that Resident #1 had not been administered the medications as ordered. Resident #1 was admitted to the Facility in April 2012 with a [DIAGNOSES REDACTED]. The Facility's Policy, titled Medication Administration, dated 6/2019, indicated the Medication Administration Record [REDACTED]. The Policy also indicated a licensed nurse would verify the current eMAR to ensure any new orders were entered correctly, and would identify any omissions, changes, or errors and communicate them immediately to the pharmacy and nurse manager daily. On 1/21/20, the Facility was found to be in Past Non-Compliance and provided the Surveyor with a plan of correction which addressed the area of concern as evidenced by: A. The Performance Improvement Action Plan Worksheet, dated 1/2020, indicated the Facility implemented a systematic change where staff would include discontinued medications as part of the comprehensive 24 hour chart reviews for all residents, and a comprehensive chart review would be performed. B. The Policy and Procedure, titled 11:00 P.M. to 7:00 A.M. shift 24 Hour Checks, dated 1/13/20, indicated the Facility's newly implemented procedure for medication change reviews to be completed every 24 hours. C. The Audit Reports, dated 1/13/20, indicated the Facility completed a comprehensive review of all residents' medication orders and order changes, and found no additional errors. D. The Education sign in sheet, dated 1/17/20, indicated nursing staff were educated regarding the newly implemented Policy for reviewing medication changes. E. The Performance Improvement Action Plan Worksheet, dated 1/2020, indicated the Facility would monitor the process changes to sustain ongoing compliance monthly at Quality Assurance Performance Improvement (QAPI) meetings. F. The Director of Nurses said the concern would be brought to QAPI for a period of three months, or until compliance was met. G. The Action Plan Worksheet indicated the Director of Nurses would be responsible for the plan of correction.

Based on observation, record review and interview, the facility failed to ensure that 2 residents, (#7 and #62), received appropriate supervision and assistance to avoid accidents resulting in injury, out of a total of 30 sampled residents. Findings include: 1. For Resident #7, the facility failed to provide appropriate supervision and assistance for the resident resulting in a fall with a subsequent [MEDICAL CONDITION]. Resident #7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set, (MDS), indicated that he/she is severely cognitively impaired and requires assistance with bathing, ambulation and transfers. The Surveyor made multiple observations of Resident #7 on 3/20/18, 3/21/18, and 3/22/18 ambulating with assistance in the facility. On 3/23/18, the Surveyor was informed that Resident #7 had fallen in the afternoon of 3/22/18, and was hospitalized with a [DIAGNOSES REDACTED]. Review of the incident report form, dated 3/22/18, indicated that a CAT scan of Resident #7's left hip showed a left comminuted intertrochanteric fracture. Review of Resident #7's clinical record indicated the following nursing note: 3/22/18, 3:45 P.M.; Resident was attempting to sit in a chair in the unit hallway. As he/she turned to sit, he/she caught her/his foot on the leg of the chair tripping her/his. He/she fell on to his/her left side before the CNA could stop himself/herself fall. Review of Resident #7's Falls care plan, dated 10/19/16, indicated the following interventions: -Monitor his/her whereabouts as he/she gets up and leaves the activity room without warning or his/her walker -Assist of one and rolling walker or arm in arm for ambulation on the unit Review of Resident #7's care planning note, dated, 3/21/18, indicated that his/her care plan was reviewed by staff on 3/16/18. The note indicated that Resident #7 required extensive assistance with transfers and ambulation, that Resident #7 was at risk for falls due to poor safety awareness and staff monitor his/her whereabouts throughout the day. During interview with CNA #1 on 3/23/18, at 2:30 P.M., she said that Resident #7 requires assistance with transfers and walking. She also said that the Resident at times refuses assistance. During interview with Nurse #1 on 3/23/18, at 2:35 P.M., she said that Resident #7 requires assistance and if he/she is seen ambulating alone, then staff should immediately attempt to assist him/her. Review of the facility's Incident Report Form submitted to the state agency on 3/23/18, indicated the following: Upon further investigation of the nature of this fall, it appears the Resident ambulated from the day room into the hallway without assistance. The Resident does require staff assist and his/her rolling walker while ambulating related to his/her impulsiveness. After discussing the fall with the staff on the unit at the time, it appears one activity aide was left alone in the day room, during the change of shift. Staff will be educated on proper change of shift procedure, (and) careplan interventions. The facility failed to provide necessary supervision and assistance to Resident #7 when ambulating from the day room to the hallway resulting in a fall with fracture. 2. For Resident #62, the facility failed to provide appropriate supervision and assistance for the Resident resulting in a fall with a subsequent ankle fracture. Resident #62 was admitted to the facility in 4/2012 with dementia. Review of a quarterly MDS completed on 8/1/17 indicated the resident had severe cognitive impairment, needed extensive assistance of 2 for transfers and toileting, and had no falls since the prior assessment, although the resident had previous falls on 3/24/17, 4/1/17 and 4/22/17. A care plan developed for Alteration in mobility related to history of falls included the following interventions: - Anticipate Resident's needs at all times. - Keep call light within reach and answer promptly. - Needs reminders to ask for assist with mobility. Review of a nurse's note dated 9/15/17 indicated at 4:45 P.M. the resident was found on the floor with the right foot /ankle twisted under left thigh. The Resident complained of pain. The doctor was called and ordered the Resident to be sent to the emergency room for an evaluation. The resident sustained [REDACTED]. Review of the facility's incident report dated 9/15/17 indicated the resident was found on the bathroom floor by a Certified Nursing Aide (CNA) #4. The right foot and ankle were slightly twisted under the thigh/gluteal area. A witness statement written by CNA #4 indicated CNA#4 went into the resident's room to answer a call light and heard banging on the bathroom door. The CNA went in the bathroom and found the Resident on the floor. The CNA stated she had checked on the resident about 15 minutes earlier and the resident refused to get up off the toilet. CNA #4 was given a formal warning on 9/17/17 for leaving the resident alone on the toilet. During an interview with CNA #5 on 3/22/18 at 1:00 P.M. she stated the resident used to be able to transfer with the assist of 2 people, but now the resident uses a mechanical lift to get out of bed and is unable to ambulate. On 3/26/18 at 2:30 P.M., the resident's fall and fracture was discussed with the Director of Nurses. She stated CNA #4 brought the resident to the bathroom and left him/her there unattended resulting in the resident falling and sustaining a fracture.

Based on observations, record review and interviews, the facility failed to develop and implement care plans related to mental health and failed to implement and review mental health services for 1 resident, (#132), out of a total of 30 sampled residents. Resident #132 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of his/her most recent Minimum Data Set, dated dated [DATE], indicated that he/she is severely cognitively impaired and required assistance with bathing, dressing and transfers. Review of Resident #132's clinical record indicated that he/she was hosptalized on [DATE], after stating that he/she wants to wrap his/her oxygen tubing around his/her neck after a family meeting occurred in which long term care was discussed. Resident #132 returned to the facility on [DATE] and the facility then developed an alteration in mood/behavior careplan. The careplan did not include individualized goals or interventions. The care plan did not address or identify Resident #132's depression or address goals or interventions regarding his/her suicidal ideation. There was no evidence that ongoing supportive services, or methods to monitor his/her mood were provided to Resident #132 after his/her hospitalization with regard to his/her depression or thoughts of suicide. Additional review of Resident #132's clinical record indicated that on 1/31/18 he/she was banging his/her head against a wall and made comments about wanting to break his/her head open. The resident was seen for a one time assessment by the Psychiatric Counselor and was then sent to the hospital. The resident returned without recommendations for medication changes or monitoring. On 2/10/18, the Resident had been removed from the lounge area after punching another resident and then told staff that he/she wanted to die and refused to put on his/her oxygen and stating he/she would die without it. Resident #132 was then sent to the hospital. The resident returned without recommendations for medication changes or monitoring. On 3/19/18, the Resident became agitated and accused another resident of stealing an item of his/hers. Resident #132 pulled a butter knife from his/her drawer, and threatened to kick the resident. Staff placed both residents on 1:1 supervision. No changes or updates to Resident #132's care plans were made. During interview with Nurse #2 on 3/21/18 at 12:10 P.M., she said that Resident #132 had threatened to stab the other resident with the butter knife. She said that staff took immediate action to monitor both residents for safety, but that she should have sent Resident #132 to the hospital. Review of the clinical record indicated that after the hospitalization s on 1/31/18 and 2/10/18, and threatening another resident on 3/19/18, the facility did not assess Resident #132's mood, depression, suicidal ideation and aggression, or implement ongoing support services. During interview with the MDS Coordinator on 3/21/18 at 9:33 A.M., she said that the alteration in mood/behavior careplan, (dated 5/22/17), that the Surveyor had been given, along with other paper care plans, had been placed in overflow and were not active at this time. She was unable to say when the care plans had been removed and therefore, ended. On 3/23/18, a careplan in regards to Resident #132's suicidal ideation was found in his/her computerized clinical record dated 5/25/17. During interview with the MDS Coordinator on 3/23/18 at 7:46 A.M., she said that Unit Manager #2 had created the suicidal ideation care plan on 3/22/18 and was not sure if it should be dated 3/22/18 or further back. Review of Resident #132's current care plans indicated that no careplan was in place regarding Resident #132's depression, anxiety, suicidal ideation, and aggressive behaviors existed or were developed between 5/22/17 and 3/21/18 for Resident #132. During interview with Unit Manager #2 on 3/21/18 at 12:57 P.M., she said that the only change in Resident #132's care after being hospitalized with suicidal ideation and behaviors was a referral to the Psychiatric Counselor on 2/21/18, and that no changes were made after the resident threatened to stab another resident on 3/19/18. On 3/21/18, at 1:54 P.M., the Surveyor interviewed the Psychiatric Counselor and the facility Social Worker jointly. Both the Social Worker and the Psychiatric Counselor said that they were not aware that Resident #132 had been hospitalized after he/she refused to wear his/her oxygen and made statements about wanting to die on 2/10/18. The Psychiatric Counselor said that she had been called in on 1/31/18 to do a one time assessment, and was not contacted by the facility again to assess or be referred for ongoing supportive counseling with the Resident until 2/21/18. The Psychiatric Counselor said the 2/21/18 referral was placed because Resident #132 was having increased tearfulness. Both the Social Worker and Psychiatric Counselor said that although staff had made them aware that Resident #132 had been aggressive towards another resident on 3/19/18, they said that they were not informed that the Resident had a butter knife and threatened to stab another resident. The Psychiatric Counselor said that the facility used to hold behavior/risk meetings where she would attend and it was useful in identifying residents who may be in need of support. She said that since those meetings are no longer held with her in attendance, she is now reliant on facility staff to make referrals. The Social Worker said that a referral for supportive counseling for Resident #132 should have been placed after his/her initial hospitalization in 5/2017. She also attributed Resident #132's behavior and suicidal ideation in 1/2018 and 2/2018 to the recent loss of his/her sibling. During interview with Resident #132 on 3/22/18 at 1:04 P.M., he/she said that he/she does like meeting with the Psychiatric Counselor to talk about how he/she is feeling and noted that he/she would have liked to have started seeing her sooner. During interview with the Director of Nursing, (DON), on 3/22/18 at 3:55 P.M., she said that the facility does not have policies on care planning for mood and behaviors, psychiatric service referral, or suicidal ideation. On 3/22/18, at 1:19 P.M., the Surveyor met with Administrator and DON and reviewed the above concerns. The Administrator said that because Resident #132 is cognitively impaired, he felt that the Resident would not benefit from counseling services. A note written by the Psychiatric Counselor on 3/21/18 at 3:24 P.M., indicated the following: Resident #132 indicated that he/she always feels better when we talk, even though he/she could not recall my name. Neither the Administrator nor the DON could explain why care plans were not developed for Resident #132 with regard to his/her depression, mood, aggression, behaviors or suicidal ideation despite his/her ongoing demonstration of depressive and aggressive symptoms.

Based on interview and record review, for one of three sampled residents (Resident #1), the facility failed to ensure that on 6/25/13, CNA #1 used a gait belt when ambulating Resident #1 from the bathroom to his/her chair, per plan of care and Use of Gait Belt Policy and Procedure. Resident #1 fell and sustained a laceration on his/her head.that required six staples at the Emergency Department (ED). Findings include: The Face sheet indicated that the staff admitted Resident #1 to the Facility in March 2006 and Resident #1's [DIAGNOSES REDACTED]. The plan of care, dated 12/26/12, related to Resident #1's fall risk, dementia, impulsivity, history of syncope, and no safety awareness, included: transfer and ambulate with one assist, gait belt, and rolling walker. The plan of care indicated that Resident #1 sometimes moved suddenly. The Quarterly Minimum Data Set (MDS) assessment, completed on 6/17/13, indicated that Resident #1 made himself/herself understood, usually understood others, and had cognitive impairment. The MDS assessment indicated that Resident #1 required extensive assist of one staff for transfer activities and ambulating. The Surveyor interviewed CNA #1 on 7/25/13, at 9:20 A.M. The Surveyor interviewed CNA #2 on 7/25/13, at 12:00 P.M. CNA #1 and CNA #2 said residents who required physical hands on assistance with walking required the use of a gait belt. CNA #1 and CNA #2 said Resident #1 had a steady gait. CNA #1 and CNA #2 said although they assisted Resident #1 to maneuver the walker when he/she ambulated to the bathroom, they did not provide physical assistance to Resident #1. CNA #1 and CNA #2 said they did not use the gait belt when they ambulated Resident #1 to the bathroom. The Surveyor interviewed CNA #3 on 7/25/13, at 12:15 P.M. The Surveyor interviewed CNA #4 on 7/25/13, at 12:45 P.M. CNA #3 and CNA #4 said they always used a gait belt when assisting Resident #1 to ambulate with the walker. CNA #3 and CNA #4 said sometimes, Resident #1 required hands on assistance with ambulating. The Surveyor interviewed Charge Nurse #1 on 7/25/13, at 10:00 A.M. Charge Nurse #1 said on occasion, she observed some of the CNAs ambulating or transferring a resident without the use of a gait belt, when a gait belt was indicated. The nurse's note, dated 6/27/13, indicated that while Resident #1 walked with his/her walker from the bathroom with the CNA beside him/her, Resident #1 turned, lost his/her balance, and fell backward. The nurse's note indicated that Resident #1 hit his/her head and had bleeding from his/her head. The nurse's note indicated that the staff transferred Resident #1 to the Emergency Department (ED). The ED report, dated 6/27/13, indicated that the Physician applied staples to Resident #1's scalp laceration. The nurse's note, dated 6/27/13, indicated that Resident #1 returned to the Facility and had six staples to his/her head. The Use of Gait Belt Policy and Procedure indicated that a gait belt was to be used for all transfers and ambulation of residents, who required physical assist with transfer and ambulation. The Use of Gait Belt Policy and Procedure indicated the following: Supervision: The resident is able to transfer and walk without direct physical contact but requires visual observation for safety. No gait belt is needed. Limited assist: Gait belt is necessary for transfer and ambulation for a resident, who may not need direct physical contact but requires cueing or guarding for balance and technique. Assist: Requires weight bearing assistance by one or two persons during transfer or ambulation. Gait belt required. The Surveyor interviewed the Director of Nurses (DON) on 7/25/13, at 8:30 A.M. The DON said Resident #1 required cueing, supervision, and physical assistance. The DON said Resident #1 required the use of a gait belt during transfer activities and ambulation. The DON said CNA #1 did not use the gait belt on Resident #1 per the plan of care.

Based on observation, record review and interviews, the facility failed to provide adequate supervision and effective interventions to prevent accidents and failed to act on a Physical Therapy recommendation in a timely manner for 1 resident (#1) in a total sample of 24 residents. Findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan initiated on 1/4/11 identified the resident as being a "high fall risk" and stated the following problem: -Potential for falls and alteration in mobility due to history of syncope, decreased strength and endurance, pain and use of cardiac/psychotropic med use. Recent history of falls. Interventions included: - Provide frequent verbal reminders about calling for assist with mobility. - Keep personal items within reach. - Pressure alarm in bed and chair at all times. - Resident ambulates up to 200 feet with rolling walker and gait belt. An initial MDS (minimum data set) completed on 1/10/11 assessed the resident as having severe cognitive impairment, needing extensive assistance for transfers and ambulation and having fallen within 30 days prior to admission. review of the resident's medical record revealed [REDACTED]. The first fall occurred on 3/16/11 at 12:45 A.M. According to the incident report the resident was found kneeling on his/her knees near the bed. The resident stated "I was walking when I lost my balance and fell ". The resident did not sustain an injury. The intervention instituted at that time, according to the incident report, was to apply a pressure alarm to the resident's bed. A quarterly MDS was completed on 4/6/11 and revealed the resident continued to have severe cognitive impairment as well as needing extensive assistance for transfers and ambulation. In addition, the resident had one fall since the prior assessment. The second fall occurred on 5/21/11 at 6:45 P.M. According to the incident report, the resident was found sitting on the floor of his/her room. The resident stated "I was getting my pants and stumbled and sat on the floor". No injury was sustained. A sensor alarm was initiated. The third fall occurred on 6/21/11 at 5:30 P.M. According to the incident report, the resident fell landing on the bathroom floor. The resident had buried the alarm beneath the bed linens, muffling the sound. The resident stated "I was going to the bathroom and I fell ". A motion detector was added to the room. A quarterly MDS dated as being completed on 7/6/11 revealed the resident had no changes in cognition, still needed extensive assistance with transfers and ambulation and had 2 falls since the last assessment. On 7/25/11 at 8:15 P.M., the resident fell for the fourth time. According to the incident report, a nurse passing medications heard the resident yell for help. When the nurse entered the resident's room, the resident was found sitting on the floor. The resident stated "I was coming out of the bathroom and I don't know what happened". The alarm did not sound. The alarm was found in the chair and not in the bed. Interventions after the fall included: - Monitor for injury. - Inservice staff. - 15 minute checks for 72 hours. - Ensure personal alarm is working. The fifth fall occurred on 8/7/11 at 4:45 P.M. The incident report stated the resident's alarm was ringing and the resident was found sitting on the floor in front of personal recliner. The resident stated "I slid out of the chair". Interventions implemented included: -Monitor for injury. - Inservice staff on keeping walker and belongings within reach. - Obtain urinalysis. In addition, on 8/11/11, a notation on the resident's fall care plan stated "room change to front of nurses' desk". A quarterly MDS (minimum data set) completed on 10/5/11 continued to code the resident as having severe cognitive impairment, needing extensive assistance for transfers and ambulation. The resident also had 2 falls since the prior assessment without sustaining an injury. The last 2 falls occurred in October. According to an incident report dated 10/17/11, the resident fell on [DATE] at 6:15 P.M. The resident was in his/her bedroom and sat on the floor after attempting to transfer himself/herself from the wheelchair to bed. The resident did not sustain an injury. Follow-up interventions included: - 15 minute checks. - Toilet on demand, toilet after supper, and put to bed. - Rehab evaluation. - Motion detector to be added. - Continue with pressure alarm in bed and chair. On 10/18/11, a physical therapy (P.T.) evaluation was conducted and a recommendation was made for a trial of the use of a clip belt. Although the resident was identified by the facility as being a high fall risk no interim plan was put into place to ensure the resident's safety. On 10/19/11, a notation was added to the care plan stating "will discuss using clip belt alarm at risk meeting on 10/25". This meeting was to be held 6 days after the Physical Therapist's recommendation. Review of an incident report dated 10/24/11 revealed the resident fell on [DATE] at 6:00 P.M. According to the incident report this was an unwitnessed fall. The resident was unsupervised in the lounge and fell out of the wheelchair. The incident report stated a certified nursing assistant (CNA) heard a thump, went into the lounge and found the resident lying on his/her left side after falling out of the wheelchair. The resident was sent to the hospital for an evaluation and was diagnosed with [REDACTED]. After the resident returned to the facility on [DATE], the facility determined the resident was to utilize a velcro seatbelt while in the wheelchair. The resident is able to self release the velcro seatbelt, so it is not considered a restraint. Review of the Treatment Administration Record for the months of November and December 2011 revealed the resident is assessed weekly on the ability to remove the seatbelt. On 11/29/11 at 1:30 P.M. the resident was observed sitting in the wheelchair in his/her room. A velcro seatbelt was attached around the resident's waist. When the surveyor asked the resident what the seatbelt was used for, the resident stated "I don't know, I guess we all have them." On 12/7/11 at 4:30 P.M., a discussion was held with the Director of Nurses about the delay in acting upon the Physical Therapist's recommendation for the trial use of a seat belt. The Director of Nurses acknowledged the delay and stated the facility was going to start to discuss falls and review recommendations at the morning meeting instead of waiting for the weekly risk meeting.